Lansing-Area Health System Agrees To Pay $671,300 To Settle False Claims Act Allegations Relating To Improper Billing

July 28, 2023

A Michigan health system (Sparrow) settled with the DOJ and agreed to pay $671,310 to resolve False Claims Act issues based on the improper billing of “incident-to” services.  Incident-to services are furnished incident to a physician’s professional services when they are an integral part of the services provided by a physician.

A couple of key points when billing incident-to:

  • The Advanced Practice Providers (APP – e.g., Nurse Practitioners and Physician Assistants) can see a patient based on the physician’s initial treatment plan and can bill under the physician’s name.
  • The reimbursement rate is 100% of the physician’s fee schedule when billed incident-to versus 85% when billed under the APP’s name & NPI.

There are several other requirements when appropriately billing incident-to services.  Check out the following references for details on incident-to requirements:

  1. Noridian MAC JE Part B –
  2. Chapter 15 Medicare Benefit Policy Manual (specifically Section 60, although there are several other sections which discuss incident to services)

The DOJ’s Press Release can be found here.

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