Doctors Targeted for NP and PA 'Overbilling'

Judith N. Aburmishan, CPA, CHBC


July 30, 2013

In This Article


Doctors whose practices work with nurse practitioners (NPs) and physician assistants (PAs) could become the focus of scrutiny, as the US Department of Health and Human Services (HHS) has vowed to take a closer look at Medicare claims submitted for nonphysician clinician services.

In the HHS Office of Inspector General (OIG) Work Plan: Fiscal Year 2013,[1] the government has targeted the billing practices of nonphysician providers to see whether their billing error rate is higher for "incident to" services than for other services billed.

"Incident to" services are those services or supplies provided as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness.

Why all this scrutiny?

The key culprits are the incident to billing regulations. Medicare authorizes 100% of the Medicare Physician Fee Schedule for procedures performed incident to a physician's office visit, even if performed by a nonphysician. When a nonphysician sees a patient for any other type of procedure, Medicare pays 85% of the Medicare Physician Fee Schedule. With the prevalence of nonphysician clinicians, there's been a resulting increase in the use of the "incident to" billing.

Here's an example of "incident to" billing: A patient has been identified as diabetic by the physician. As part of the treatment plan, the physician asks the patient to get laboratory work done and see a dietitian for diabetic counseling, and then come into the office for a follow-up visit. The NP then sees the patient for the follow-up visit. This visit would be billed to Medicare at 100% of the physician fee schedule as a visit "incident to" the original visit. If the visit was billed as a nonphysician visit, the fee would be 85% of the approved physician fee schedule.

Given that the differential between "incident to" and standard billing for a nonphysician provider is 15% of collections, it would be very beneficial for the physician to identify all of the proper "incident to" situations at the same time to avoid the trap of overbilling.

So let's review the Medicare regulations. "For services to be considered 'incident to,' there first must have been a direct, personal and professional service furnished by the physician to initiate the course of treatment." New patient visits as well as established patient visits for new complaints must be seen first by the physician, so that a course of treatment can be planned. If the nonphysician sees the patient first, the billing cannot be labeled "incident to."

Once the patient course of treatment has been established, a nonphysician provider can perform any follow-up work. For this additional service to be billed as "incident to," it must be personally furnished or incident to the physician's professional service by an employee under immediate personal supervision, except as otherwise expressly permitted by the regulations.


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