Medicare Compliance & Reimbursement

Tip: Remember incident-to billing is under close scrutiny for audit and OIG enforcement.

Before you begin the hiring process for a non-physician practitioner (NPP), such as a nurse practitioner (NP) or physician assistant (PA), it’s good to do a reality check. Adding an NPP might appear to be a smart move given the additional income you can expect to generate. But you’ll need to do some advance preparation to make sure the new hire has a positive impact on your bottom line.

Start With the Positives

Adding an NP or PA to your practice can have many benefits. First, you will likely be able to have more patients flow through the office each day. “NPPs can be a valuable asset to a medical practice,” says Nicole Orofino, CPC, owner of Innovative Coding Analysis in Allentown, Penn.

“NPPs such as ARNPs and PAs can provide care to more patients within a practice,” agrees coding, billing, and practice management consultant Steven M. Verno, CMBS, CMSCS, CEMCS, CPM-MCS, in Orlando, Fla.

In addition to allowing the practice to see more patients in general, NPPs also allow the physicians to focus on more complicated or serious cases. “As an example, an emergency care practice can have NPPs assist with seeing more patients in the emergency room providing relief to an overburdened physician-patient system,” Verno says. “This leaves the emergency care physician with the ability to treat the more serious patients, leaving the minor injuries and minor illnesses to be seen by the NPP.”

Logically, when your practice can see more patients more efficiently, your practice income should increase as well. “NPPs can help increase revenue to a practice when more patients are seen,” Verno says.

Bonus: There are even more benefits. “Patient satisfaction increases due to extended visits and same-day appointments, and physicians are less harried when NPs help eliminate patient backlog,” Orofino adds. “They can increase the size of patient panels, producing larger capitation payments in managed care markets, and allow doctors to concentrate on better-paying cases with fee-for-service plans.”

Don’t Forget the Negatives

While your practice may decide that hiring an NPP will bring many benefits, you should also do your due diligence and make sure there are no hurdles to jump to reap those rewards.

“While I wouldn’t consider the addition of NPPs a downside, there are many steps that must be taken to ensure a smooth successful onboarding,” Orofino cautions. She says the following areas will require analysis and planning prior to hiring an NPP and prior to your NPP’s first day:

• How you will utilize the NPP;
• Whether your practice is financially ready to hire additional clinical staff;
• If there are research programs your physicians participate in where the NPP can assist with clinical trial documentation and program regulations;
• Determine how long it takes for a patient to get an appointment with one of your physicians;
• Introduction of your new NPP to your patient population;
• Collaborative agreements and the scope of practice parameters the NPP will follow for your organization;
• Malpractice insurance;
• Decision making on how the NPP’s revenue will be distributed amongst the partners of the practice;
• EMR set up for clinical documentation;
• Billing set up in your practice management system including the set up of cost centers and the routing of revenue;
• Insurance credentialing;
• Hospital privilege requisitions if the NPP will be assisting with hospital rounds.

Check Scope of Practice Limitations

Different states, and even different payers, place limits on the types of services NPPs can perform. So before hiring an NP or PA, your practice will need to determine what those providers can actually do in the practice and decide which provider is best and what services they will provide.

“NPPs are limited to their scope of practice as to what they can provide based on their medical license limitations and state law limitations,” Verno says. “Some insurance companies do not recognize services rendered by NPPs and as such will deny claims sent to them when the claim reports that the provider is an NPP. This can be very costly to a practice when an NP or PA provides care to a patient with Medicare as primary and XXX insurance as secondary (XXX replaces the name of a real insurance company). Medicare recognizes services provided by NPPs and will pay the claim. The downside is that Medicare doesn’t pay 100 percent of the physician fee schedule. Medicare will send the claim to XXX insurance. XXX insurance will deny the claim requiring the billing company or practice to spend administrative expenses to try and overturn the denial.”

To help avoid these issues, you should research your state laws as well as the rules of payers for your locale, especially those that the practice contracts with before you hire an NPP.

Review Other Important Details

Check the credentialing requirements and timing for each payer as well, Orofino says. “Not all payers recognize NPPs. Credentialing for those who do takes time,” she adds. “Get all of your new NPP’s credentialing documents as soon as possible after an employment arrangement has been executed so you may begin the credentialing process ASAP.”

You will also need to review the guidelines for billing NPP services. Brush up on your incident-to knowledge to ensure that your claims are not denied and to ensure you bring in the most revenue possible. “Spend the time and cost if necessary to educate yourself and your staff on incident-to billing guidelines prior to billing for your NPP,” Orofino says. “Incident-to billing is a high area of audit and OIG scrutiny.”

Read more: You can learn more about incident-to billing guidelines in the article on page 150 and Medicare Compliance & Reimbursement, Vol. 39, No. 18.