Medical Billing Forum

General Category => General Questions => Topic started by: becca051 on February 13, 2014, 12:17:08 PM

Title: billing nurse practitioners
Post by: becca051 on February 13, 2014, 12:17:08 PM
i have a question about billing nurse practitioners....we are in the state of mo and coventry, umr and uhc do not credential nurse practitioners....we were told by the insurance companies since they do not credential them to bill under the physician in the office and that incident to billing doesnt apply since they dont credential them....our auditors say otherwise...Is there a specific rule for billing nurse practitioners in this situation or does incident to billing actually apply? The ins gave us verbal instructions to bill under the physician but nothing in writing and the auditors want it in writing.

Any information would be great
Title: Re: billing nurse practitioners
Post by: PMRNC on February 13, 2014, 02:23:01 PM
The insurance company should never tell you how to file a claim and they are in correct. The NP would have to be listed as the rendering provider, there's now way around that legally.
Title: Re: billing nurse practitioners
Post by: Merry on February 14, 2014, 10:59:00 AM
I did some research on this and I was surprised to see how many insurance companies tell you one thing yet refuse to put it in writing.
Since the NP's are not credentialed, they cannot be put in as a rendering provider, but my question would be why couldn't they be billed as "incident to".

Would like to see this conversation continue as I am perplexed.

Merry

Title: Re: billing nurse practitioners
Post by: shanbull on February 14, 2014, 12:14:05 PM
I did some research on this and I was surprised to see how many insurance companies tell you one thing yet refuse to put it in writing.
Since the NP's are not credentialed, they cannot be put in as a rendering provider, but my question would be why couldn't they be billed as "incident to".

Would like to see this conversation continue as I am perplexed.

Merry

We had this situation with an NP when she first started, everyone including Medicare told us to bill with our MD as both the billing and rendering provider until the NP had her own credentials sorted out. Even after that, some insurance companies kept telling us they weren't going to credential her individually and they would accept claims only if the billing and rendering provider were the MD and the NP was listed as the "resource". We thought this was all crazy and made our network managers assure us this was the only option. I still think it's crazy but we actually did have some of these claims audited by one of the insurance companies (Medica, owned by UHC) and they were fine with it. I still wouldn't recommend doing it without getting instructions to do so in writing from each insurance company. And I still don't understand the logic behind it. Seems much less messy to just credential the NP's. Especially because more and more are going to be coming down the pipeline due to MD shortages. I don't think the MD's are going to continue to be ok with it either. Someone else billing under your NPI is a great way to get nailed for fraud over something the other person did. The credentials on the line are the MD's.
Title: Re: billing nurse practitioners
Post by: RichardP on February 14, 2014, 01:43:39 PM
The insurance company should never tell you how to file a claim and they are in correct. The NP would have to be listed as the rendering provider, there's now way around that legally.

Traditionally, Federal law supersedes State law, unless the State law is more strict (contains everything the Federal law does, plus more).  I don't know if State law supersedes CMS regulations in this instance, but I invite you to read through my comment(s) at the following link.

In California, we operate according to the info in the attached blurb, and have no trouble getting paid by anybody.  That is, we bill the work done by the NP under the name of the doctor.  We put no info in Box 24J for Commercial carriers and they have nothing to indicate that the work was done by anyone other than the doctor.  For Medicare, they require the NPs Type 1 NPI Number (who did the work) in Box 24J - but we still bill under the doctor's Type 2 NPI Number (who gets paid).

The info from the link down to the [end quote] is a direct quote from the CMS Manual.

http://www.medicalbillinglive.com/members/index.php?topic=7045.msg21031#msg21031

This is the relevant bit:

A supplier [of medical services; a physician] may be an individual, partnership, corporation, trust, or estate. Any services furnished by an employee of the supplier are considered furnished by the supplier if those services are within the scope of the employment.

Think in terms of the doctor's nurse.  She does many things that the doctor bills for.  But the doctor bills for them in his name.  Same general idea applies to PAs, NPs, etc.  The difference here being that, if they qualify for it and have the appropriate NPI Number, PAs, NPs, etc. can bill in their own name if they want to - they will just get paid less than if the doctor bills for their work under his name.

becca051 - the link to that quote is given inside the link provided above.  That should cover your need for something in writing.
Title: Re: billing nurse practitioners
Post by: Merry on February 14, 2014, 01:50:40 PM
I knew that you,  Richard, would come to the rescue. Thanks so much. Since I am in CA also, I am careful to post what I know for this state as everyone knows we do things so differently. :)

Merry
Title: Re: billing nurse practitioners
Post by: RichardP on February 14, 2014, 01:52:43 PM
Merry - this type of question comes up quite a bit, and I refer the questioner to that link.  But the question of whether State law can supersede CMS regulations in this instance suddenly confronts me.  That is something I had not thought of before.  I know California allows us to bill like this.  Do you or anyone else know whether other State laws might forbid billing like this?
Title: Re: billing nurse practitioners
Post by: Michele on February 14, 2014, 05:59:35 PM
We bill like that in NY too, but I don't personally do any now.  In the past, with the insurance carriers that did not credential NPs they just billed out services under the md.  I just had no place to refer them to as to why that is so. 
Title: Re: billing nurse practitioners
Post by: Merry on February 14, 2014, 10:06:43 PM
I don't know the different state laws. I do know whichever law is more stringent is the one that "counts". How is that for legalese?
Title: Re: billing nurse practitioners
Post by: becca051 on February 17, 2014, 10:17:57 AM
this is all great info and i appreciate it! so lets say the physician isnt in that day and our nurse practitioner sees a patient with one of these insurances can we actually bill with the physicians name since he isnt in office that day? our auditor says that we would have to bill alond incident to guidelines in order to bill under the physicians name and he isnt always in the office.

thanks again!
Title: Re: billing nurse practitioners
Post by: RichardP on February 17, 2014, 11:55:55 AM
We researched this issue for our clients who wanted to add NPs to their office.  The term "supervision" has a specific meaning and is defined by each State.  A health-care attorney familiar with your State laws can help you determine how your State defines supervision.

For California, "supervision" is defined as being in the same room with the NP all the way up to being in the same city and immediately available by phone.  That is, the NP is considered to be "supervised" by the doctor so long as the doctor is in the same city as the office the NP is practicing in, and the doctor is immediately available by phone.

As an aside, think how this could work in California.  Doctor could have two offices.  Sees the wealthier patients in one office.  Sees the Obamacare patients in the other, where the NP does the work.  Has iPads in each office, connected by Skype.  NP doesn't know what s/he is looking at.  Skypes the doctor, and points the iPad camera at the target issue.  Doctor sees the image on his iPad screen and offers his informed opinion.  NP says "thanks", breaks the connection, and gets on with the work.

Billers - sell that idea to your clients.  They can increase their patient load and make money off of Obamacare, all without increasing their own level of stress.  But only if your State defines supervision as "being in the same city, immediately available by phone".  And only if the income from the Obamacare office is high enough to cover all expenses associated with the second office and the NP, etc.  (That idea is presented with tongue only slightly in cheek.)
Title: Re: billing nurse practitioners
Post by: Merry on February 17, 2014, 03:11:56 PM
Love it..You are definitely the creative one.
Title: Re: billing nurse practitioners
Post by: PMRNC on February 17, 2014, 03:12:57 PM
This is not related to NP however I once did a big whistleblower case on a provider not following the "supervision rules". He was going away on vacations and still I was getting charge slips for the type of provider that had to be supervised.     Be careful.
Title: Re: billing nurse practitioners
Post by: PMRNC on February 17, 2014, 03:14:35 PM
Quote
Billers - sell that idea to your clients.  They can increase their patient load and make money off of Obamacare,

There is no such thing as "OBAMACARE"   EVERY practice has to take a look and review very carefully ALL plan contracts for the "All products clause".  THERE is no Obamacare.   
Title: Re: billing nurse practitioners
Post by: dermbillerPA on March 04, 2014, 09:18:44 AM
Quote
Billers - sell that idea to your clients.  They can increase their patient load and make money off of Obamacare,

There is no such thing as "OBAMACARE"   EVERY practice has to take a look and review very carefully ALL plan contracts for the "All products clause".  THERE is no Obamacare.   

Thank you for saying that!!!!
I just went through this process.  MD adding a PA.  I had to research/call every MD contracted carrier to get their requirements.  About 50% don't credential NPP's so must be billed as incident to.  Some just wanted the MD to update his demographics and the others wanted new applications.  There is a CMS MLN Matters Article Number SE0441 regarding incident to.  I was not able to attach the pdf article to this msg.  CMS does require direct supervision.
Title: Re: billing nurse practitioners
Post by: RichardP on March 06, 2014, 12:10:17 AM
There is no such thing as "OBAMACARE"   EVERY practice has to take a look and review very carefully ALL plan contracts for the "All products clause".  THERE is no Obamacare.

Yup.  That is why I said that I was offering my idea with tongue only slightly in cheek.  But ...

Yes there is such a thing as Obamacare, or ACA if you prefer.  Note the following.  This is important for those who don't know about it.

In California, those Carriers participating in the Exchange sent notices to all physicians about accepting ACA patients.  I believe the requirement was to opt in, but I'm not absolutely certain of that.  At any rate, none of our clients opted in.  "Not gonna participate in Obamacare" they all proclaimed.  The majority of our clients are non-participating providers anyway, so this doesn't matter for them.  But we have a couple of clients who are participating providers for Commercial Carriers.

I have been seeing insurance cards with dental provisions on them recently, so I know that some folks who have been patients for years are switching to getting their insurance through the exchanges (or maybe all plans must now include dental??).  At any rate, for the couple of Par Providers, suddenly Blue Cross / Blue Shield has stopped paying for the ACA customers.  Inquiries as to why yielded the following answer:  you had a chance to sign up to be a Participating Provider for the ACA folks, and you didn't do that.  Therefore, while you are a Par Provider for our regular customers, you are Non-Par for our ACA folks.  Because you are Non-Par for them, we are sending payment to the patient, not to you the Provider.

I know this will not be true for all of these newly-minted Obamacare patients, but it will be true for some:  they will get the payment from the Insurance Carrier and won't pay the doctor.  It is for these patients I suggested a second office, staffed by a lower-cost Nurse Practitioner.  Let the NP see all the patients who get the check straight from the Insurance Carrier and won't pay the doctor / NP.  Sure-fire way for going out of business.
Title: Re: billing nurse practitioners
Post by: PMRNC on March 06, 2014, 06:58:56 AM
Quote
In California, those Carriers participating in the Exchange sent notices to all physicians about accepting ACA patients.  I believe the requirement was to opt in, but I'm not absolutely certain of that

Yes that's exactly what happened in many states. Those providers not par with that carrier or if they are and did NOT have an all payor clause (some states don't allow for all payor clauses), found themselves OUT of network unless they "opted in".

All product clauses are proprietary, in the case of BCBS in California, doctors were opting out not realizing that carriers were invoking the "all product clause". This only became news to doctors when patients started coming through the door, but in reality we were warned about this way ahead of time. Suddenly the credentialing department is overflowed now with reviewing contracts. In some states "all product clauses" can't be invoked. What we did was go through all of the contracts for each provider by the carriers participating in the exchange plans. Those plans that had all product clauses were noted and office was given a crash course in identifying exchange plan patients. Long before the ACA came into play, providers just wanted to "par with all BCBS plans" and did not give much thought to what that meant.  Now it matters.  Little tip if you do credentialing: This is a good time to review contracts and contract verbiage along with renewal terms.