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"Incident to" -- Is Changing


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From CMS this morning:

 

CMS will also allow more “flexibility” in the supervision of clinical staff who provide care coordination services. Under the rule, physicians can bill “incident to” services provided by clinical staff members, even if they are not direct employees and are under general, but not direct, supervision.

CMS said the rules for “incident to” services are somewhat looser than usual because of the nature of non-face-to-face care coordination, which often involves after-hours contact with nurses and coordination with providers who are not direct employees of the physician practice.

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I did not get through all of it

 

BUT 

 

This looks to specifically apply to CCM and TCM (Chronic Care Management & Transitional Care Management)

 

CCM is a new code that pays about $42 per month, for documenting > 20 min of time spent on the phone with care mangement

TCM - deals with care after a hospital admit - and the requirements managing this are too hard to figure out as well as the  "OBS STATUS' issue which makes TCM impossible to bill.

 

 

I couldn't read far enough into this with out falling asleep to see if there was any mention of actual office visits as incident to...... would be nice to be able to bill my house calls at the 100 % level and not be committing fraud - right now I bill everything under myself as the doc is in the office and I am in the home.....

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So I read through this and it only effects us peripherally if I understand it correctly. For background, PAs and NPs can provide services incident to a physicians services. However, other staff such as nurses or medical assistants can be billed for incident to services for physicians or other providers (which included not only PAs and NPs but others such as social workers). The main change here is previously if you saw a patient and then had them come back to see the nurse for a wound check and dressing change it had to be under direct supervision for you to bill incident to for the nurses visit (99211). This removes that requirement and uses general supervision instead. Whether this applies just to CCM and TCM or other situations I would have to read more deeply. It also removes this requirement for federally funded rural health clinics. Overall it doesn't appear to change how PAs are affected by incident to. It also is in comment so its not final legislation. 

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Incident to needs to go away......

 

 

the dirty little secret is this

 

most primary care office hire a PA - pay maybe 100k per year, but then bill everything out as 'incident to' and collect the same reimbursement as if they had hired a doc - 

 

So some hard numbers

 

Practice hires doc - Doc salary min 150k, then bennies/overhead of 100k - if the collect 300k the practice makes 50k

Practice hires PA - PA salary 100k, then 80k bennies/overhead - if we collect the same 300k practice makes 120k,

                                                                                           if we collect 250k, practice makes 70k

Either way the  practice makes more money by doing everything 'incident to' - which when I looked into it is okay as long as the SP is in the suite and immediately available for consult....

 

 

BUT

If hire a PA at same numbers as above but the PA only get 85% of collections the 300k goes to 255k and the 250k goes to about 190k - which really hurts their profit

 

Biggest way to get an opposition to changing the regs is to propose something that makes the owners/docs make less money across the board.  Also would hurt PAs paid on productivity.  in general it only helps the insurance company spend less, it hurts the PA and the Practice.

 

Why not just make incident to 85% go away!  We are not assistants and honestly the biggest expense with medicine is overhead and this is the same for PA MD NP

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Why not just make incident to 85% go away!  We are not assistants and honestly the biggest expense with medicine is overhead and this is the same for PA MD NP

 

I agree.  We don't give 85% of good care.

 

I've spend a few hours studying this new CMS proposal. As usual, it is a labyrinth of references, inside abbreviations and confusion that would make it hard for anyone short of a Harvard Healthcare Law professor to understand it.

 

With that said, the new part appears to be;

 

1) To follow incentive to, previously the physician would have to be in the building, the "to" person (usually the SP) would have to be in the building as well as to have seen the patient for the original problem.

 

2) The PA doesn't have to be an employee of the "to" person or group, where as before they did.

 

3) Other staff can deliver care that a PA normally did, and it can be billed incident to the PA or other non-physician provider (really poorly defined in the articles).

 

4) These are the final rules after two years of debate and will become law in Jan 2015.

 

So this is my understanding after reading the original text, and several commentaries by physician groups and lawyers who are trying to make sense out of this.  But I could be totally wrong.

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  • 4 weeks later...

The change only applies to CCM and TCM services. Everything else stays the same. Basically this is allowing non physician providers to bill incident to for these services and eliminating the need to be direct employees.

 

In a practical sense, a physician can contract with a firm specializing in care management to do the chronic care management of the physician's patients and still bill it under the physician.

 

Why does it make sense? You can involve more specialized practitioners in the management of the patient. A practice can support a Nurse or PA, but can any single practice hire a Pharmacist to aid in chronic care management? Probably not. That would be where you contract out the pharmacist and he serves multiple practices, billing incident to for each physician, even though he isn't a direct employee.

 

 

Sent from my iPad using Tapatalk

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so how does this apply to my situation

 

I have my own practice, I bill everything under my PIN except VNA cert and recert which goes under the doc's name (as he is the only one that can bill it)

 

But I pay him a hefty portion of the billings as it is a Doc only code.....

 

(outside of his employment contract issues)

 

I could bill CCM under his pin, and get the higher reimbursement correct?

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Correct. It seems like it won't have a huge impact on you other than the ability to bill the CCM under him for the higher reimbursement.

 

I mentioned this to one of our practice administrators yesterday and asked her to dig into it a little more because it isn't something that has been exceptionally high on my radar. If she comes back with something, I'll let you know.

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  • 1 year later...

The multispecialty orthopedic group I have worked with for over ten years has routinely billed incident-to for every patient seen by the PAs. I have worked in a nearly autonomous clinic with my supervising physician present in the office only 25% of the time. He is either on vacation, away from the office or at a satellite clinic 100 miles away. Our contracted billing company recently advised that the physicians were "walking a fine line" with their utilization of incident-to. The physicians went on record as saying they would continue to walk the fine line rather than lose revenue. Can anyone tell me if this constitutes fraudulent billing and should I be worried?

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The multispecialty orthopedic group I have worked with for over ten years has routinely billed incident-to for every patient seen by the PAs. I have worked in a nearly autonomous clinic with my supervising physician present in the office only 25% of the time. He is either on vacation, away from the office or at a satellite clinic 100 miles away. Our contracted billing company recently advised that the physicians were "walking a fine line" with their utilization of incident-to. The physicians went on record as saying they would continue to walk the fine line rather than lose revenue. Can anyone tell me if this constitutes fraudulent billing and should I be worried?

Yes and yes

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The multispecialty orthopedic group I have worked with for over ten years has routinely billed incident-to for every patient seen by the PAs. I have worked in a nearly autonomous clinic with my supervising physician present in the office only 25% of the time. He is either on vacation, away from the office or at a satellite clinic 100 miles away. Our contracted billing company recently advised that the physicians were "walking a fine line" with their utilization of incident-to. The physicians went on record as saying they would continue to walk the fine line rather than lose revenue. Can anyone tell me if this constitutes fraudulent billing and should I be worried?

Yes it's fraud and you already know it.

 

It sounds like someone will be taking a fall for this soon. The billing company already put it in writing and gave a stern warning. They will be the whistleblower. The whistleblower can receive from 15% up to 30% of the amount that the Government recovers thanks to the whistleblower. I would make sure your employer understands this and then start looking for a new job.

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I was actually just seeing if there were any astute individuals listening in on the forum. The group has been pushing the boundaries with respect to ethical treatment of the PAs in the group and recently just crossed the line with me. I could give a shit about recovering any money I just want to see a bunch of greedy pricks get what coming to them. I will inform the billing company that I'm going public with the information and they can either join me or be part of the criminal indictment. I'll let you know how it plays out.

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Fernwwod,  you are probably liable too and you may need to get your own lawyer.  Even though you have no control over how your clinic bills, you are part of the fraud scheme by association.

 

I think you might want to consult a lawyer first to see if you can cover yourself.  From now forward you need to make sure your billing is under your own NPI number. 

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I will speak as a heartless lawyer (said with tongue and cheek humor and if you are a lawyer, don't take offense).  You also have the option to function as a "whistleblower,"  which would not only protect you but would give you 1/3 to 1/2 (I think) of the penalties as a Qui-tam case.  Of course, this would mean you would never work there again and they will hate you the rest of your life, but depending on how much the penalty is, you may never need to work again.

 

Your employer may be nice people who are just confused (then I, personally would not do this). Or they may be greedy people who knew what they were doing (then I would consider it).

 

I started a Qui-tam case once against a group that was the later. They had hired me to "see patients" but once I moved there, it was set up so that I would never see  a patient and my salary was based on productivity.  They had knowingly hired me to fit into a complex billing (fraudulent) scheme for Medicare and Medicaid using my credentials. I had called CMS to talk about what to do (when the AAPA would not return my calls) and it was CMS guy in Washington DC that encourage me to sue them via Qui-tam.

 

My lawyer took so long (he was busy with other cases for over a year), in the end we did not meet the requirements of Qui-tam per time between offense and suit filed, and just sued them for breach of contract and prevailed.

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