Medical billing is a complex and highly regulated process that requires meticulous attention to detail and compliance with various rules and guidelines. One aspect of medical billing that often raises questions is ‘incident-to-billing.’ This blog post explores incident-to-billing, its importance, and how it impacts healthcare providers and patients.
What is Incident-to-Billing?
Incident-to-billing is a billing method used in healthcare to describe a situation in which non-physician healthcare providers (such as nurse practitioners, physician assistants, and clinical nurse specialists) provide services to patients under the supervision of a physician. This method allows these non-physician providers to bill for their services under the physician’s National Provider Identifier (NPI) number, which can be advantageous in certain situations.
Incident-to-billing applies only to professional services billed to Medicare.
Importance of Incident-to Billing
Incident-to-billing is important for several reasons:
- Cost-Effective Care: It allows healthcare practices to leverage the skills of non-physician providers to deliver cost-effective care to patients. This is especially valuable in primary care settings and areas with a shortage of physicians.
- Enhanced Access to Care: Incident-to-billing can increase patient access to healthcare services by expanding the pool of qualified providers who can see patients. This is particularly relevant in rural and underserved areas.
- Billing Efficiency: Allowing non-physician providers to bill under a supervising physician’s NPI simplifies billing, reducing administrative burdens for providers and payers.
Understanding the Requirements for Incident-to-Billing
To utilize incident-to-billing, specific requirements must be met:
- Location of Services: The medical examination should occur within what is referred to as a ‘place of service 11 (office).’ According to the Centers for Medicare and Medicaid Services, place of service 11 (office) is defined as a location distinct from a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF). If the service isn’t provided in place of service 11, you are not eligible for incident-to-billing claims.
- Supervision: The physician must provide direct supervision to the non-physician provider. This means the physician must be physically present in the office suite where the service is being rendered. Supervision can also be achieved through real-time audio and video communication for telehealth services.
- Established Plan of Care: The patient must have an established plan of care established by the physician. This plan should include a clear diagnosis and treatment plan.
- Initial Encounter: The initial encounter between the patient and the physician should establish the patient’s diagnosis and treatment plan. The non-physician provider may conduct subsequent visits.
- Continuity of Care: The physician must remain actively involved in the patient’s care and periodically see the patient for follow-up visits. The non-physician provider should not deviate from the established plan of care.
- Scope of Practice: The services provided by the non-physician provider must be within their scope of practice and licensure.
Impact of Incident-to-Billing for Providers and Patients
Incident-to-billing has both positive and negative impacts on healthcare providers and patients:
Benefits for Providers:
- Enhanced efficiency in delivering care.
- Increased revenue potential.
- Greater flexibility in staffing.
Challenges for Providers:
- Increased administrative complexity.
- Stricter adherence to supervision and documentation requirements.
- Potential for billing errors and compliance issues.
Benefits for Patients:
- Improved access to care, especially in underserved areas.
- Increased availability of healthcare services.
- Cost-effective care options.
Challenges for Patients:
- Potential variations in the level of care provided.
- Limited choice in selecting a healthcare provider.
- Dependency on the supervising physician’s schedule.
Incident-to-billing is a valuable tool that allows non-physician healthcare providers to work under the supervision of a physician while billing for their services under the physician’s NPI number. It can enhance access to care, improve cost-effectiveness, and streamline the billing process.
However, it comes with strict requirements and potential challenges for providers and patients. As healthcare regulations evolve, understanding incident-to-billing remains crucial for healthcare practices seeking to optimize their services and revenue while delivering quality patient care.
Do you need help with understanding incident-to-billing guidelines for 2023? Book a free consultation with us today by calling (727) 202-5429. We have been helping medical professionals and group practices since 2003 with a proven track record in delivering results.