Posted and filed under FWA.

Stringent billing guidelines and regulations are often instituted to limit the incidence of fraud, waste, and abuse (FWA). Specificity increases annually, providing a well-developed outline for physicians and billers. Revisions to billing procedures are designed to help all facets of the healthcare industry.

An example is incident-to billing, which was introduced to address the trend of pairing non-physician practitioners (NPP) with a particular physician, and billing under that physician’s provider number. With incident-to billing, supervised NPPs can provide care and bill incident-to physician service. Reimbursement is made at 100% of the Medicare Physician Fee Schedule (MPFS) for incident-to services, compared to 85% for non-incident-to services.

Though these provisions are useful for healthcare teams to manage patient care, the ambiguity that surrounds incident-to and signature regulations is setting providers up for failure. The proof is in the audit trail.

Defining “supervising” is an area of misunderstanding. In the proposed rule for CY 2016, CMS explains that a “supervising” – or “billing” – physician is not required to be the ordering or original physician on the patient’s case. To meet the incident-to rule, a physician must evaluate the patient to setup the plan of care; follow-up visits can be performed by the NPP and billed incident-to as long as the plan is followed and a supervising physician is in the same suite. The supervising physician does not necessarily have to be the same physician who sets the plan of care. Recognizing this may be physically impossible given provider schedules, on-call coverage, and holidays. Bill incident-to services under the physician’s number who actually provided the supervision service. The example below highlights this confusion:

A Pennsylvania-based family practice provider billed a high-level Evaluation and Management (E/M) claim. During the review of the medical record, incident-to billing was identified. The NPP’s name and signature was found in the chart notes. The audit revealed there was no counter signature from a supervising physician, who was off-site at the time. Note: a counter signature is a state-level regulation for a full recoupment of the E/M service.

The situation described does not meet the incident-to guidelines, which calls for a paradigm shift in practices revolving around NPP-physician partnerships. Missing a counter signature was the “smoking gun” in the case above. Continuing this workflow creates a risk for being accused of FWA. The true supervisor must be the billing physician.

There are minimal disadvantages of conducting incident-to audits. The risk of noncompliance will outweigh the administrative time and costs of finding overpayments upfront. Audits require looking at years of data to identify if the NPP followed plans of care. New issues should be billed under the NPP’s Medicare ID, and incident-to does not apply.

The largest benefit of conducting incident-to audits is protecting your financial flow. Nevertheless, incident-to audits pose road blocks for investigators. In the long run, receiving the 85% for non-incident-to services versus the 100% allowed amount will eliminate noncompliance, along with any possible FWA of incident-to services.