Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Clarifying Anthem “Incident to” and Midlevel Reimbursement

At the recent Indiana State Medical Association Commercial Payer Forum, members expressed continued confusion to representatives from Anthem over their rules for billing “incident to” services, as well as when services should be billed under nurse practitioners or physician assistants directly.

“Incident to” services are defined by the Centers for Medicare and Medicaid Services (CMS) as “services that are furnished incident to physician professional services in the physician’s office or in a patient’s home.” Also, these services must be all of the following: “an integral part of the patient’s treatment course; commonly rendered without charge (included in the physician’s bills); of a type commonly furnished in a physician’s office or clinic (not in an institutional setting); and an expense to the physician.”

In an Anthem update from April 25, 2012, Anthem provided their own clarification: “incident to” services are provided by “non-physicians under direct supervision by a supervising provider, that are integral to the care of the patient.” The services will be reimbursed by Anthem, if separately reported, “as if the supervising provider had personally provided the services” if they meet Anthem’s definition of medically necessary and would be otherwise covered.

To be separately reported, the supervising provider must be present in the office suite and immediately available when necessary to provide assistance and direction while these “incident to” services are being provided, and must stay involved and have an active part of the ongoing care.

Where Anthem differs from CMS guidelines for “incident to” services is that any provider assigned an Anthem ID must have services billed out under his own NPI, and is not eligible in an “incident to” scenario. Additionally, only providers for whom Anthem does not ordinarily provide an ID if requested can submit claims in an “incident to” scenario.

In other words, “services rendered by any provider who is eligible, under Anthem policies, to directly submit claims to Anthem for reimbursement [including nurse practitioners and physician assistants], regardless of whether NPP has or has not applied for an NPI or whether an application for an NPI is pending” are not eligible for reimbursement as “incident to” services.

Anthem will begin auditing claims for compliance to their “incident to” policy later in 2012.

Midlevel providers, including NPs, PAs, certified nurse midwives, and clinical nurse specialists, have been credentialed by Anthem since 2004 and have been paid at a reduced rate (85%) for most CPT codes since that time.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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