by Cheryl Nash
Are you considering adding a physician assistant (PA) or non–physician practitioner (NNP) to your practice? Seems like a great idea, right? Well, in a lot of ways it is. But there are details you need to be aware of prior to implementing such a plan.
Having Clear Expectations
The first item to consider is job description: What are you expecting your NPP to do? Obviously to help balance an increasing workload in a practice, a midlevel provider can be a wonderful asset, but who they see and what they do will be a very large consideration. A clear job description will aid in addressing these concerns and also assist in a credentialing plan for the various payers to ensure your investment has a return.
Here are some questions to consider regarding your NPP
• Will they be providing services on a strictly incident to basis?
• Will they be doing initial evaluations and diagnosing patients?
• Will they assist in surgical services?
Each of these items have differing guidelines that will need to be followed, and having a clear idea of what services you expect your NPP to perform will make the process easier.
Know Your State’s Requirements
The second item is to understand your state’s requirements for NPP licensing and scope of practice. You need to ensure that the job you want the PA or NP to do is within the state guidelines. If it is not, then rethinking your ancillary staffing may be in order. A great resource for this type of information can be found for PAs at the American Academy of Physician Assistants. The site links you to state-specific laws through the federal and state advocacy page. A similar site exists for NPs. A call to your state medical board and to your medical malpractice lawyer is also suggested.
Great, so you have done your homework and have found that an NPP would be a good fit. What steps to take now?
Payer’s Requirements: What Are They?
The next item to investigate is your payer’s requirements. Understanding your various payers’ billing requirements is the first step in avoiding compliance issues. Let’s break them down a bit.
Medicare. While this is the biggest fish in the sea, it is also the best defined when it comes to NPPs. Medicare has very clear rules and guidelines to follow, and will credential a PA or NP in their own right to allow a practice more freedom with its nonphysician staff. The rules can be broken down into two main categories: incident-to billing and direct billing.
Incident-to billing is when a practice submits claims for services rendered by an NPP under the supervising physician’s NPI number. This results in reimbursement at the standard physician fee schedule. The rules defining incidentto are very strict and can be found at www.cms.gov under the Medicare Claims Processing Manual. Medicare states that services that qualify as incident-to “must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. You do not have to be physically present in the patient’s treatment room while these services are provided, but you must provide direct supervision, that is, you must be present in the office suite to render assistance, if necessary. The patient record should document the essential requirements for incident to service” (MLN Matters, article se0441). This description is of course only the tip of the iceberg, and doing a bit of research on Medicare’s website is highly recommended to understand all the nuances of this type of billing.
Some practices will find these guidelines difficult to follow and may want to consider direct billing. This allows the NPP to bill as a rendering provider in their own right. Enrollment paperwork must be filed, and there is a reduction in reimbursement for services performed this way since NPPs are paid at 85% of the physician fee schedule. However, the freedom allowed is greater and may be more beneficial to the practice. The NPP may see the patient without the supervising physician being in the office and will also be able to perform initial evaluations and order diagnostic studies. Higher-level services such as minor surgical services may still not be allowed, however, and researching both the Medicare and state requirements will be necessary prior to assigning these out.
Commercial payers are not as clear, unfortunately. Some payers will separately enroll an NPP and follow CMS rules, but not all. Some payers will cover NPP services, but they may not credential them. Most will follow the state guidelines for scope of practice, but this also may not always be the case. While reading the provider manual for each individual payer may answer most of these questions, a phone call to the contracting department will help ensure compliance and understanding of any variances in policies.
Proper research cannot be stressed enough to be sure there are no compliance issues down the road. It may seem somewhat daunting, but in reality a qualified NPP can bring success to any practice, as long as the rules are understood. As with all things in this business, nothing is truly easy, but the rewards can be great if you know what you are working with.