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Disclaimer HBE Advisors LLC has prepared the following information based on current available information as of the date of this presentation. Attendees should be aware that regulatory, coding, and billing information changes frequently, and the information contained in these slides may become outdated quickly. This information is not intended to replace job specific training and should only be used as a reference after confirming the accuracy and applicability of the information based upon current published laws, statutes, regulations, and guidelines. We have provided links to several source agencies to assist in locating current information after the date of this presentation. C o py right 20 20 HB E A d v isors LLC 3/19 /20 20 2

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Agenda ▪ Medicare “incident to” billing rules ▪ Medicare locum tenens billing rules ▪ Auditing and monitoring strategies ▪ Internal controls and best practices to promote compliance 3/19 /20 20 C o py right 20 20 HB E A d v isors LLC 3

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Medicare “Incident to” Billing Rules 3/19 /20 20 C o py right 20 20 HB E A d v isors LLC 4

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Medicare “Incident to” Billing Rules ▪ Medicare provision, although private payers may have similar policies. ▪ Defined as “services or supplies that are furnished “incident to” a physician’s professional service when the services or supplies are furnished 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 and the services are performed in the physician’s office.” ▪ To qualify for payment, the services must be part of a patient’s normal course of treatment, during which the physician personally performed an initial service and remains actively involved in the ongoing course of treatment. C o py right 20 20 HB E A d v isors LLC 5 3/19 /20 20

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Medicare “Incident to” Billing Rules ▪ Coverage is available for the services of such nonphysician personnel as nurses, technicians and therapists when furnished “incident to” the professional services of a physician/nonphysician practitioner. ▪ Medicare also pays for services rendered by employees of a clinical psychologist (CP), nurse practitioner (NP), certified nurse midwife (CNM), physician assistant (PA)or clinical nurse specialist (CNS) only when all “incident to” criteria are met. ▪ “Incident to” services supervised by non-physician practitioners are reimbursed at 85%. C o py right 20 20 HB E A d v isors LLC 6 3/19 /20 20

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Medicare “Incident to” Billing Rules ▪ In order to qualify for payment, the following criteria must be met: ▪ Services must be rendered under the direct supervision of the physician, CP, NP, CNM, CNS, or in the case of a physician directed clinic, the physician assistant (PA). ▪ The services are furnished as an integral, although incidental, part of the physician’s, CP’s, NP’s, CNM’s, or CNS’s professional services in the course of the diagnosis or treatment of an illness or injury. ▪ Billing “incident to” a qualified provider, the provider must initiate treatment and see the patient at a frequency that reflects his/her active involvement in the patient’s case. This includes both new patients and established patients being seen for new problems. C o py right 20 20 HB E A d v isors LLC 7 3/19 /20 20

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Medicare “Incident to” Billing Rules ▪ There must be a valid employment arrangement between the physician, CP, NP, CNM, CNS, or physician directed clinic, and the employee. ▪ The physician/nonphysician practitioner cannot hire and supervise a professional whose scope of practice is outside the provider’s own scope of practice. ▪ Services must be rendered under direct supervision. The physician/nonphysician practitioner (or a physician/nonphysician member of the group) must be present in the office suite and immediately available to provide assistance and direction throughout the time the employee is performing the services. ▪ Immediately available means the supervising physician/nonphysician is readily available and without delay to assist and take over the care as necessary. C o py right 20 20 HB E A d v isors LLC 8 3/19 /20 20

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Medicare “Incident to” Billing Rules Example Rendering Proper Billing Established patient, no new problems NPP If “incident to” requirements have been met, the service may be billed under the supervising physician’s NPI Established patient, new problem NPP Must be billed under the NPP’s NPI Established patient, new problem NPP and Physician If “incident to” requirements have been met, the service may be billed under the physician’s NPI. The documentation must support the physician performed a portion of the face-to-face encounter and initiated the course of treatment. New patient NPP Must be billed under the NPP’s NPI. C o py right 20 20 HB E A d v isors LLC 9 3/19 /20 20

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Medicare “Incident to” Billing Rules ▪ Common “incident to” billing errors: ▪ Billing for new problems or patients ▪ Billing for services not included in the physician treatment plan ▪ Billing for services rendered in a hospital, SNF, etc. ▪ Anything other than POS 11 ▪ Billing for services that don’t meet direct supervision criteria ▪ Billing for services rendered by non-employees ▪ Billing for services which exceed an employees scope of license ▪ Billing “incident to” to payers who do not allow/recognize the provisions C o py right 20 20 HB E A d v isors LLC 10 3/19 /20 20

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Medicare “Incident to” Billing Rules ▪ There is a significant payment differential (15%) between services performed and billed by a NP/PA under their provider number vs. services billed under a physician provider number. ▪ This payment differential creates compliance risk. ▪ In January, a family practice physician settled false claims allegations made by the DOJ related to “incident to” billing. ▪ Physician agreed to pay $285,000. ▪ Services rendered by nurse practitioners were billed using the physician’s provider number even though the direct supervision requirements were not met. C o py right 20 20 HB E A d v isors LLC 11 3/19 /20 20

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Medicare “Incident to” Billing Rules ▪ “Incident to” has been the subject of multiple DOJ settlements and OIG reports. ▪ There has been substantial pressure on CMS to eliminate the provisions altogether. ▪ In the June 2019 Medicare Payment Advisory Commission (MedPAC) report to Congress, the commission unanimously recommended that Medicare eliminate the “incident to” provisions. ▪ It would not be a surprise to find this recommendation addressed in the 2021 Proposed Physician Fee Schedule. C o py right 20 20 HB E A d v isors LLC 12 3/19 /20 20

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Medicare Locum Tenens Billing Rules 3/19 /20 20 C o py right 20 20 HB E A d v isors LLC 13

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Medicare Locum Tenens Billing Rules ▪ Medicare provision, although private payers may have similar policies ▪ Over the last couple of years, Medicare discontinued the term “locum tenens” and now officially references the rules as “Fee-for- Time Compensation Arrangements”. ▪ For simplicity where this presentation uses the term “locum tenens”, the official Medicare rules for “Fee-for-Time Compensation Arrangements” apply. ▪ Provisions allow a physician to retain a substitute physician to take over his/her professional practice when the physician is absent for reasons such as illness, pregnancy, vacation, or continuing medical education, and for the regular physician to bill and receive payment for the substitute physician’s services as though he/she performed them. C o py right 20 20 HB E A d v isors LLC 14 3/19 /20 20

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Medicare Locum Tenens Billing Rules ▪ In order to bill under these provisions, the following criteria must be met: ▪ Regular physician is unavailable to provide services ▪ Medicare beneficiary seeks services from the regular physician ▪ Regular physician pays fee-for-time compensation arrangement physician (locum) for his/her services on a per diem or similar fee-for-time basis ▪ Substitute physician (locum) does not provide services to patients over a continuous period of longer than 60 days ▪ Regular physician retains records of the substitute physician’s (locum) NPI. These records must be available upon request. ▪ Claims for the services rendered by the locum must be submitted with the Q6 modifier (services furnished by a fee-for- time compensation arrangement physician). C o py right 20 20 HB E A d v isors LLC 15 3/19 /20 20

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Medicare Locum Tenens Billing Rules ▪ Services rendered by non-physician practitioners (i.e. CRNA, NP, PA, etc.) may not be billed under fee-for-time compensation arrangements (locum). ▪ There are limited exceptions for physical therapy. ▪ There is an exception to the 60-day limitation. If the regular physician is called to active duty military, then the locum may provide continuous services for longer than 60 days. ▪ Services rendered during the initial 60-day period are billed under the regular physician’s NPI with the Q6 modifier. ▪ Services beyond the initial 60-day period, must be billed with the substitute physician’s (locum) NPI. ▪ The regular physician may not personally provide and bill services during the same time period as the locum. C o py right 20 20 HB E A d v isors LLC 16 3/19 /20

 

 

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