billing medicare for non-Physician Providers By Richard R. Wier, Jr., Esq. BECOME FLUENT IN THE FEDERAL RULES T he Centers for Medicare and Medicaid Services (CMS) and federal law enforcement agencies have increased efforts to combat healthcare fraud. In order to help fund these efforts, the Patient Protection and Affordable Care Act (PPACA) has increased the Health Care Fraud and Abuse Control Program’s funding by $350 million from fiscal year 2011 to fiscal year 2020. As a result of these increased efforts and funding, in October 2012, the Medicare Fraud Strike Force charged 91 individuals, including doctors, nurses, and other licensed medical professionals, for their participation in falsely billing the Medicare program, resulting in approximately $429.2 million in penalties. according to the false claims act, fraudulent billing under medicare includes, but is not limited to, billing for tests not performed, performing inappropriate or unnecessary procedures, upcoding by using more expensive billing codes when lower priced procedures were performed, and various other billing inflation practices. When billing, health care providers must remain vigilant of the ever-changing billing and coding laws and pertinent state regulations to ensure that they are not improperly submitting medicare claims. one billing issue that may arise is the improper billing of non-Physician Providers (nPPs), such as physician’s assistants, nurse practitioners, and clinical nurse specialists. nPPs are able to enroll and bill medicare for services that they are licensed or certified to perform within the state. When nPPs work independently, they are recognized under medicare for professional billing and are able to bill medicare under their own medicare provider numbers; however, the reimbursement by medicare is only 85% of the medicare Physician fee 24 hbma billing • may. june.2013 schedule (mPfs). the mPfs provides the billing codes and proper coding methods that are required when requesting reimbursement from medicare for services provided. conversely, nPPs who perform services that are incident to the physician’s course of treatment, which are known as “incident-to services,” can bill medicare for the services provided by the nPP under the physician’s medicare provider number, and the health care provider would receive 100% reimbursement from medicare under the mPfs. in order for nPPs to bill incident-to services, medicare requires that the physician perform an initial visit with the patient in order to establish the physician-patient relationship. after the initial visit, the physician does not need to be involved in each patient visit, but must actively participate in the management of the course of treatment for the patient. although not required by medicare, some carriers require that the physician meet with the patient every third visit or when a new symptom or medical issue arises. When determining whether to bill for services provided by the nPP independently or incident-to the physician’s services, health care providers must verify the scope of practice for the nPP, the place of service, and physician supervision over the nPP. there are a variety of resources available for guidance, including title 42 of the code of federal regulations (cfr); coding and billing under the medicare Physician fee schedules (mPfs), as previously mentioned; and state laws and regulations. the cfr is a federal law that provides minimal standards necessary for billing under medicare. health care providers must keep in mind, however, that it is imperative to look at state law first because it may be more stringent than the federal law. state law will specify the scope of practice, certification and licensing, and level of supervision required for each type of nPP, and these factors determine whether the
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