Billing for Mid-level Providers

There is a lot of confusion and questions about how and when to bill for mid-level providers.  If you have a new mid-level in your practice for the first time, then you might not know what “incident-to” billing is. You may not even know what the difference is between billing for a mid-level provider versus a physician. Merem Healthcare Solutions can offer insight for medical practice billing providers of all sizes. First, we want to help you understand the differences.

Direct billing versus incident-to Billing

“What is the difference in reimbursement?” is the number one question we are asked by practice administrators. The simple answer is, mid-level providers generally get paid 85% of what the physician is paid when billing under their own NPI (direct billing) versus billing under their supervising physicians NPI (incident-to).

Some providers think they should always bill incident-to because of this reason. However, you must know the rules before making the decision on how to bill for your mid-level provider.  To learn more about Medicare billing requirements, you can reference our blog explaining Incident-to Billing.

In order to satisfy Medicare requirements, the PA must work with a physician who is responsible for the direction and management of the mid-levels activities and for ensuring that the services provided are appropriate. The physician supervisor does not need to be present when the PA furnishes a service unless state law states otherwise. If the physician is not present, he or she must be immediately available to the PA for a telephone consultation. However, even if the physician is immediately available, that does not mean you can bill under the physicians NPI (incident-to). If the patient is following the mid-level provider’s plan of care and the physician has never seen the patient, then you must bill under the mid-level for most insurances. This means in most cases the mid-level will receive on average, 85% of the physician fee schedule.

On the other hand, if the mid-level is following the physician’s plan of care and they are in the same office suite, then you can bill under the physician (incident-to) and receive 100% of the fee schedule.

Example: Billing Incident-to

After evaluating the patient the physician decides to bring the patient back to their office for an injection. If during that visit the mid-level provides the injection under the direction of the physician it can be billed as “incident-to” for most payers and be paid 100% of the physician’s fee schedule.

Note: The provider must cosign the medical record for the visit.

For more information on mid-level billing and physician billing, contact Merem Healthcare Solutions. Your practice or facility will have a skilled and experienced partner providing comprehensive management of your revenue cycle from Charge Entry to Payment Posting and Patient Statement Submission. Let us worry about billing guidelines while you focus on your patients!