Balancing the Risk & Reward of Incident-to-Billing

Live FREE Event 2024: Reconsidering the Risks with Incident-to-Billing

• Webinar registration: https://register.gotowebinar.com/register/1272913846835693663
• Webinar date: July 24, 2024
• Webinar time: 2:00 pm
• Webinar Speakers: Robert W. Liles, J.D., M.B.A., M.S. with Liles Parker & Shannon DeConda with NAMAS, a division of DoctorsManagement, LLC

With the extensive reimbursement cuts of 2023 and 2024, medical practices are urgently pursuing ways to optimize their revenue while maintaining compliance with regulatory standards. One strategy that is often seen as an elusive unicorn for physician practices is making incident-to-billing work on all the right occasions, compliantly. Incident-to is a provision under Medicare that allows services provided by non-physician practitioners (NPPs) to be billed under a supervising physician’s National Provider Identifier (NPI) for a higher reimbursement rate. Specifically, services billed incident-to are reimbursed at 100% of the physician fee schedule, compared to the 85% typically afforded to NPPs billing independently.

At first glance, the additional 15% reimbursement might seem like a straightforward financial advantage. However, the complexities and stringent requirements associated with incident-to-billing introduce significant risks that must be carefully weighed against the potential financial benefits. As reimbursement rates across the healthcare sector continue to decline, for many, the risk of pursuing incident-to becomes overshadowed by the urgent need for financial restitution.

For years, many healthcare consultants and health law attorneys have advised clients to direct bill rather than run the gamble with the risks associated with incident-to-billing. However, considering the continued reimbursement reductions facing physicians year over year, it could be time for this messaging to change. This article explores the circumstances under which the recommendation to avoid incident-to-billing might shift, identifying when and for whom this approach might become a viable strategy.

NPP as the Incident-to SME

Incident-to-billing cannot work without a team that thoroughly understands the ins and outs of the rules and guidelines. This time, the team members needing to understand the billing guidelines in real time aren’t your billers but the NPPs. One of the first steps in creating a viable incident-to-billing program is ensuring that each NPP who will be billing incident-to becomes a subject matter expert (SME) in incident-to. 

Commitment to Learning and Compliance

NPPs who are not on board with continuous education and training regarding Medicare’s incident-to regulations should be direct-billed. The practice is also encouraged to consider a different compensation model for these NPPs. 

The need to be engaged in education, learn the rules, and have a thorough understanding is key due to the extensive guidelines. This includes understanding the following key requirements:

1. Direct Supervision: The supervising physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the NPP performs the service.

• This requires an NPP who is cognizant of their surroundings and the schedules of others, not just themselves.
• The NPP must know what to do when direct supervision is not met.

2. Integral Part of Physician’s Service: The service provided by the NPP must be an integral, although incidental, part of the physician’s professional service.

• This sentence can read foreign, and the NPP needs to understand this.
• Ensuring the physician’s presence in patient care is crucial to incident-to-billing. Additionally, compliance is key to defining the cadence of physician visits relative to NPP visits and ensuring the NPP properly schedules follow-up appointments with the appropriate provider.

3. Established Patient and Plan of Care: The patient must be established, and the service must be part of a treatment plan initiated by the supervising physician.

• Educating the NPP on how to handle New Patients on their schedule.
• Identifying which established patients meet incident-to-guidelines

4. Documentation: Thorough documentation is crucial. 

• Documentation that includes a reference to an established treatment plan by the physician.
• A statement indicating a continuation of the treatment to validate that incident-to criteria are met.

Physician Education and Responsibilities

For incident-to-billing to be successful and compliant, physician education is as crucial as training for non-physician practitioners (NPPs). Physicians must understand their significant role in this process, along with ALL risks of incident-to occurring under their name to government and commercial payers, as every claim, right or wrong, is billed out under their own NPI. 

Additionally, the physician is responsible for the key documentation of the treatment plan. The treatment plan is the roadmap for all services that the NPP will follow for the treatment of each patient. 

Real-Time Decision Making

The NPP is often the only one who can determine if the incident-to-billing criteria are met at the time of service. This is due in part to:

• Immediate Assessment: The NPP can immediately assess whether the supervising physician is available and whether the service aligns with the established care plan.
• Documentation Accuracy: Ensuring the originating treatment plan is consistent with the presenting problem and that the documentation of the current encounter accurately reflects compliance with incident-to rules.

Implement Incident-to-Billing Successfully

Practices that successfully implement incident-to-billing by adhering to these rules can experience increased revenue.

However, it’s important to note that these benefits come with the responsibility of maintaining strict compliance. The risk of audits and potential penalties for non-compliance necessitates a disciplined and well-documented approach to incident-to-billing.

In summary, incident-to-billing can be a viable and beneficial strategy for physician practices, but only if they have NPPs who are committed to understanding and applying the rules consistently. By investing in the necessary education and performing ongoing audits to ensure meticulous compliance standards are met, these practices can navigate the complexities of incident-to-billing and leverage it to enhance their financial performance amidst challenging reimbursement landscapes.