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Incident-to Means You Must Have Employment Relationship, or You Lose on Pay

Set up the wrong employment relationship with your nonphysician practitioners (NPPs), and you’ll forfeit the ability to bill their services incident-to your physicians and miss out on an additional 15% of their reimbursement. Or worse, you could bill incident-to incorrectly and get targeted for an audit and be required to pay back all the reimbursement you’ve received along with hefty penalties and fines.

The trick is that your NPPs must work for — and therefore be an expense of — your practice. You can add them on as an employee or a contractor. According to the Centers for Medicare and Medicaid Services (CMS), it doesn’t matter if your NPPs are full time, part time or leased.

Also, how you pay your NPPs usually doesn’t matter either. For instance, you don’t have to show whether you reimburse them as an hourly or salaried worker.

The most important determining factor when billing incident-to services is that you must be able to demonstrate that your NPP is “under the control” of your doctor. You must be able to show that your physician is supervising and instructing your NPPs’ work. Your NPP can easily demonstrate this in their patient documentation by referencing your physician’s established care plan and involvement with the patient’s treatments.

Generally, you have a lot of leeway here. Medicare and other payers indicate that if you have an NPP helping in a practice or clinic, you may be able to bill her services as incident-to. But be careful about stepping over Medicare’s “fuzzy” line because if could severely impact your ability to bill services as incident-to.

Note: In some cases, even a temporary staffer can qualify, as long as they are an expense to the practice and you meet the other incident-to requirements.

Take Aways:

  • An incident-to provider must be an employee or contractor of a practice to bill any services in this manner.
  • An NPP can be full-time, part-time, leased or contracted and still meet the requirements for incident-to billing.
  • How you pay an employee or contractor does not affect your ability to bill their services as incident-to.

To learn more about coding and billing for incident-to services, check out the following Coding Leader training and tools:

P.S. You can view all upcoming live online training sessions at https://codingleader.com/pages/online-training-calendar.

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