Wiki Incident-To and HMOs?

[toria11]

Could someone please confirm this for me? We're trying to navigate authorization/referral requirement questions while educating our staff on the rules of incident-to billing. If a patient has an HMO and we get a referral/auth for the doctor, then the patient sees the ARNP instead, and the ARNP bills for the visit (not incident-to), the office needs a separate referral/auth for the ARNP, correct? The provider on the auth has to match the provider billing for the visit, from what I understand. I'm sure this varies payer to payer, but that's always been the rule as far as I know.

 

[sls314]

Could someone please confirm this for me? We're trying to navigate authorization/referral requirement questions while educating our staff on the rules of incident-to billing. If a patient has an HMO and we get a referral/auth for the doctor, then the patient sees the ARNP instead, and the ARNP bills for the visit (not incident-to), the office needs a separate referral/auth for the ARNP, correct? The provider on the auth has to match the provider billing for the visit, from what I understand. I'm sure this varies payer to payer, but that's always been the rule as far as I know.

I would typically expect that the referral needs to match the provider the patient actually saw. (Different HMOs could have different rules, of course, but speaking in generalities.)

Would it be possible to have the initial visit with the physician to establish the treatment plan?

 

[toria11]

I would typically expect that the referral needs to match the provider the patient actually saw. (Different HMOs could have different rules, of course, but speaking in generalities.)

Would it be possible to have the initial visit with the physician to establish the treatment plan?

Yes, that's what I would expect as well. And yes, but if the APP addresses a new problem or makes a change not outlined in the treatment plan, we would need an updated referral. Which can be tricky, especially if you think it's going to be an incident-to visit, you have a referral for the doctor, but then the patient brings up a new issue at the appointment.

 

[csperoni]

It's been a while since I needed to work denials like this, but if an ACP is working under the physician, and there is a valid referral for the physician, an appeal letter explaining got the claim paid. Particularly in some larger practices, you may have several ACPs. A patient might come in once every 2 weeks and see several different ACPs. You would need to obtain 5 different referrals all for the same patient. I don't recall ever not receiving payment after an appeal letter explaining. But again, it's been YEARS.

 

[toria11]

It's been a while since I needed to work denials like this, but if an ACP is working under the physician, and there is a valid referral for the physician, an appeal letter explaining got the claim paid. Particularly in some larger practices, you may have several ACPs. A patient might come in once every 2 weeks and see several different ACPs. You would need to obtain 5 different referrals all for the same patient. I don't recall ever not receiving payment after an appeal letter explaining. But again, it's been YEARS.

An appeal would definitely be the next step if it were to get denied! I'm just not sure how to argue that the APP is working "under" the physician when they have their own NPI and bill the visit with it, ya know?

 

[csperoni]

Even though the ACP has an individual NPI, they are all under the same TIN and working for the same employer. Same group NPI.
In fact, many states require ACPs to have some type of collaborative agreement or may not be able to work independently.
But regardless of that, it's the same group NPI. I believe it's box 17 of the CMS 1500 where you can enter who the supervising physician was (not incident-to services).