THE QUESTION: I’M THINKING ABOUT HIRING A NURSE PRACTITIONER OR PHYSICIAN ASSISTANT…HOW DOES THE BILLING WORK?
Long answer…I’m going to make more questions than I answer here I think…
Can the midlevel bill under the MD?
In short, yes…but you have to be careful and adhere to the regulatory guidelines. This is known as incident-to billing.
Why would I bill this way instead of under the midlevel directly?
In short, if you bill under the midlevel, claims will pay less, to the tune of roughly 80-85% of your contract rate, typically (check your contracts – this is a rule of thumb so there may be a bit of variation). Also, you have to go through the process of contracting/credentialing.
What are the incident-to guidelines?
There are several guidelines, but in short:
- The MD must initiate the plan of care (AKA be there on visit one)
- The MD must “actively” participate in the course of treatment (this is not a sign off and forget it thing)
- The MD must be available to provide assistance (AKA don’t be out of the state, or building
A few decent articles with more detail:
AAPC – https://www.aapc.com/blog/44912-seven-incident-to-billing-requirements/
CMS – https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf
Why are you hiring a midlevel? To help with clinic? To assist in surgery? To drive cosmetic revenue? The percentage and type of billable visits may drive how much you even want to concentrate on incident-to-billing. If you want your NP/PA to crank through injectables and they’re not going to see medical patients…who cares about insurance billing UNLESS you want to set yourself up for flexibility? Is the juice worth the squeeze on setting up your operational workflows and/or knocking out the additional contracting/credentialing projects? Mayhaps? Do you really want to stretch your midlevel between medical treatments and cosmetic where they’re likely incentivized with commissions…hard to pull them in two directions…