Can a Non-Credentialed Provider Bill Under Another Provider?

Billing for services provided by non-credentialed professionals under the oversight of a credentialed one presents a challenge for healthcare providers. Understanding the specific regulations and scenarios that permit such billing practices is important for compliance and appropriate reimbursement. These rules dictate when and how a provider’s services can be billed under another’s credentials.

Understanding “Incident-To” Billing

“Incident-to” billing is a Medicare Part B concept that allows services performed by non-physician practitioners (NPPs) or auxiliary personnel to be billed under a supervising physician’s National Provider Identifier (NPI). This method permits services to be reimbursed at 100% of the Medicare physician fee schedule, rather than the lower rate (typically 85%) often applied when NPPs bill independently.

A “non-credentialed provider” in this context generally refers to auxiliary personnel who do not have their own Medicare billing privileges, such as medical assistants, nurses, or technicians. It can also refer to non-physician practitioners like Nurse Practitioners (NPs) or Physician Assistants (PAs) when their services are billed under the physician’s NPI, as opposed to their own.

Specific Conditions for Incident-To Billing

For a service to qualify for “incident-to” billing, several conditions must be met regarding the service, setting, and physician involvement. The service must be an integral, though incidental, part of the physician’s professional service in the diagnosis or treatment of an injury or illness.

“Direct supervision” mandates that the supervising physician must be present in the office suite and immediately available to render assistance if needed. The physician does not need to be in the same room as the patient or the auxiliary personnel, but they must be physically on-site and readily accessible.

The Medicare-credentialed physician must have personally performed the initial service or established the plan of care for the specific condition being treated. “Incident-to” billing does not apply to new patients or to established patients who present with new or worsened complaints that require a new diagnosis or treatment plan. In such cases, the service must be billed under the NPP’s own NPI or by the physician.

The service must also be of a type commonly furnished in a physician’s office or clinic, signifying that it is appropriate for an outpatient setting. This excludes institutional settings like hospitals or skilled nursing facilities, where “incident-to” rules generally do not apply. Services provided outside the office, such as in a patient’s home, are covered “incident-to” only if there is direct personal supervision by the physician.

Eligible personnel include:
Non-physician practitioners (NPPs) such as Nurse Practitioners (NPs), Physician Assistants (PAs), Clinical Nurse Specialists (CNSs), and Certified Nurse Midwives (CNMs).
Auxiliary personnel like medical assistants, nurses, and technicians, who are employees, leased employees, or independent contractors of the billing entity.

These personnel must be acting within their scope of practice and the services must be medically necessary and covered by Medicare.

Documentation for Incident-To Services

Documentation must support “incident-to” billing and compliance. The medical record must clearly indicate the presence of the supervising physician in the office suite at the time the service was rendered.

The patient’s record needs to contain explicit documentation of the physician’s initial service or the established plan of care for the patient’s condition.

A detailed description of the service provided, its medical necessity, and how it relates to the physician’s overarching care plan is needed. If the NPP makes a change to the established plan of care, such as altering medication, the service may no longer qualify for “incident-to” billing and should be billed under the NPP’s own provider number.

While Medicare does not generally require the supervising physician to co-sign notes for “incident-to” services, state laws or specific payer policies might impose such requirements. The documentation should clearly name the supervising physician.

Payer Variations and Considerations

While Medicare Part B sets the primary framework for “incident-to” billing, other payers, including Medicaid programs and commercial insurance companies, may adopt, modify, or disregard these rules. Providers must verify specific policies with each payer for compliance and reimbursement.

Medicaid programs, which are state-administered, often have their own distinct rules regarding “incident-to” billing, and some may not recognize the concept at all. Many state Medicaid programs require direct credentialing of non-physician practitioners (NPPs) and independent billing under their own National Provider Identifiers (NPIs). This means that services provided by NPPs might be reimbursed differently or require different submission methods depending on the state’s Medicaid regulations.

Commercial insurance companies also exhibit significant variability in their “incident-to” policies. Some commercial payers may mirror Medicare’s “incident-to” rules, allowing for similar billing practices, while others explicitly prohibit “incident-to” billing or have specific contractual agreements that dictate different guidelines. For instance, some commercial plans may reduce the reimbursement for “incident-to” services or require that NPPs bill directly under their own NPI for all services. Understanding each commercial payer’s specific reimbursement policy helps avoid denials and ensures payment.

Billing Independently as a Non-Physician Practitioner

Many non-physician practitioners (NPPs), such as Nurse Practitioners (NPs) and Physician Assistants (PAs), are eligible to be directly credentialed and bill for their services independently under their own National Provider Identifier (NPI). This is a distinct billing method from “incident-to.”

Direct billing allows NPPs to receive direct reimbursement for their services, often at 85% of the physician fee schedule for Medicare, compared to the 100% rate for “incident-to” services.

The requirements for independent billing typically include obtaining individual state licensure, securing their own NPI, and enrolling with various payers, including Medicare, Medicaid, and commercial insurance companies. This process ensures that NPPs are recognized as independent providers capable of submitting claims for their professional services.

Direct billing is often necessary or preferred in situations where “incident-to” billing criteria are not met, such as when direct physician supervision is not available or when services are rendered in institutional settings like hospitals. It also applies when an established patient presents with a new problem, or for a new patient visit, where a physician’s initial service and plan of care have not yet been established.