Physicians should examine insurer contracts, provider policy and procedure manuals to ensure compliance
If you employ nurse practitioners or physician assistants, you should make sure you’re complying with each payer’s protocols when billing for services provided by nonphysicians. TAFP has recently heard from members who thought they were billing properly but have found themselves under investigation by payers. If these practices are found to be out of compliance, they may owe payers substantial refunds.
Many payers pay reduced fees for services provided by NPs and PAs but the rules and billing procedures doctors should follow when filing claims differ from payer to payer. For instance, Blue Cross Blue Shield of Texas pays 15 percent less for services provided by NPs or PAs than they would for services provided by the supervising physician. The insurer requires that practices include a “Modifier SA” when filing claims to indicate that a service was performed by an NP or a PA.
Other payers do not require the modifier and instead require other forms of notification. If a practice has not been following those protocols and has been receiving full payment for services as though they were provided by a physician, the practice could be required to refund the insurer for the overpayment.
“There are so many different complexities to this that it has every single primary care doctor confused,” says Bradley Reiner of Reiner Consulting and Associates, TAFP’s practice management consultant. He believes many physicians may not be aware of these requirements and may be at risk if audited. “It is absolutely critical that any physician who is considering hiring a PA or NP or who has an existing physician extender review their contracts with insurers and the provider policy and procedure manuals for each of their payers to make sure they know how these services are supposed to be billed.”
Here is a list of billing procedures insurers might require when filing claims for services provided by NPs and PAs, but we are fairly certain this is not a complete list. Physicians should check their contracts and the provider policy and procedures manuals for each of their payers to make sure they are following the correct protocols.
- Some payers require practices to bill under the physician’s name using the modifier SA for services provided by NPs or PAs.
- For Medicaid, The Texas Medicaid and Healthcare Partnership requires practices to use modifier U7 for services provided by PAs, and to use modifier SA for services provided by NPs. The Texas Medicaid Providers Procedure Manual also allows NPs and PAs to be credentialed, and Reiner suggests physicians check with their Medicaid managed care plans to make sure they are following the proper procedures.
- Some payers will credential NPs or PAs. They may require practices to bill under Unique Physician Identification Number or the National Provider Identifier of the NP or PA who provided the service.
- Payers may require practices to bill under the physician’s name but include on the claim the UPIN or NPI of the NP or PA who provided the service.
- Some payers follow Medicare’s “incident to” guidelines, whereby if an NP or PA provides a service to a physician’s established patient while that supervising physician is on the premises, the physician may bill for the service as though he or she personally provided it.
- Some payers may not pay at a different rate for services provided by an NP or PA, so the practice can bill under the physician’s name as though he or she personally provided the service.
Reiner says these protocols are not new and have likely been on the books for each insurer for some time. “I think this is coming up now because there are more and more primary care physicians hiring physician extenders and with that comes understanding how to bill for those services properly. A lot of physician don’t understand that and so we’re beginning to see payers looking at this a little more carefully because, hey, it’s an opportunity to get a little money back.”