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:
- Noridian MAC JE Part B – https://med.noridianmedicare.com/web/jeb/topics/incident-to-services
- Chapter 15 Medicare Benefit Policy Manual (specifically Section 60, although there are several other sections which discuss incident to services) https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
The DOJ’s Press Release can be found here.