Tag: Non-Physician Practitioner (NPP)
Aetna Reverses NPP Payment Reduction
By: Hannah Wisterman ~ 2/12/25
On January 31st, InK reported Aetna was changing it’s policy on billing for Non-Physician Providers (NPP). As of February 10th Aetna has changed their stand. Please Read!
Aetna’s Feb. 10 reversal preserves NPPs’ ability to fully bill under a supervising physician’s name and National Provider Identifier (NPI) for services “incidental to” the physician’s diagnosis and treatment of an injury or illness. Services billed incident-to must be conducted in the same office suite where the physician is present and available to intervene if needed.
Aetna Cuts Payment for NPP-Care
By Alisa Pierce ~ TMA
UPDATE: Please see update to this article, posted 2/13/25
Starting April 1, Aetna will pay physician practices only 85% of the Medicare Physician Fee Schedule’s allowed amounts for services provided by non-physician practitioners (NPPs)
This will be regardless of whether you bill Medicare directly or “incident-to” physician supervision.
- Both direct and incident-to claims will still be required to include modifiers SA or SB to indicate what type of NPP rendered the service, such as a nurse practitioner or certified nurse midwife.
- NPPs will still be required to be employed by supervising physicians and registered with the Texas Medical Board as having delegated prescriptive authority.
“This is essentially [Aetna] getting rid of incident-to billing,”
TMA “Ask the Expert” Virtual Series
Today’s “Ask the Expert” subject “How to Delegate to Non-physician Practioners” will be available On-Demand in a couple weeks. The link to access the recording will be www.texmed.org/asktheexpert.
UPCOMING TOPICS
Nonphysician Practitioners and Scope of Practice
TMA Ask the Expert Virtual Event
August 17th at 1 PM
How to Delegate to Nonphysician Practitioners.
Nonphysician Practitioners and Scope of Practice, a TMA Ask the Expert virtual event, will teach participants how to comply with state laws and regulations on delegating and supervising prescriptive authority. Join Carra Benson, TMA manager of practice management and reimbursement services; Dan Finch, TMA vice president of advocacy; and Julian Rivera, health law partner at Husch Blackwell, on Aug. 17 at noon CT.
BCBS UPDATE 5/12/2021
SA Modifier and Midlevel Provider Contracting Update.
On January 19, 2021, Blue Cross and Blue Shield of Texas (BCBSTX) posted an article regarding contracting and credentialing midlevel providers and the upcoming implementation of the ClaimsXtenTM edit of the SA modifier for non-payable services resulting in the SA modifier being non-reimbursable. This edit has not been implemented and there are currently no plans for future implementation of this edit.
SA Modifier Reminder
The SA modifier should be used:
- By the supervising physician, when he/she is billing for services rendered by a Physician Assistant (PA), Advanced Practice Nurse (APN), Certified Registered Nurse First Assistant (CRNFA) or Licensed Surgical Assistant (LSA).
- On claims submissions by PA or APN’s when billing under their own NPI number for assisting with any other non-surgical procedures.
This information can be found in the Clinical Payment and Coding Policies – Modifier Reference Guideline located on the provider website. Information about the reimbursement amount for the SA modifier is available in the Reimbursement Schedules and Related Information (Secure Content) area of the General Reimbursement information page. You will need a password to access this information which can be obtained from your local Network Management Office location.
UHC Cuts NPP Payments
A recent UnitedHealthcare (UHC) policy will not only cut payments by 15% to physicians who employ nonphysician providers (NPPs), but also cause needless confusion in the billing process.
That’s according to a letter the Texas Medical Association wrote to the insurer expressing concern over the policy, which took effect March 1.
UHC in December announced a policy that requires advanced practice nurses and physician assistants to bill for their services using their own National Provider Identifier (NPI) when they have not met “incident-to” billing requirements.
Payments billed using an NPP’s NPI number are typically 85% of the physician’s rate.
Despite medicine’s concerns, UHC further revised its policy in March to require that services provided by NPPs will be eligible for incident-to consideration – and thus the full 100% payment – only if the NPPs do not have their own NPI number.
That policy is scheduled to take effect May 1.
“It is TMA’s policy on physician assistants and allied health personnel that reimbursement for services performed by a physician assistant should be made directly to the responsible physician,” TMA wrote in a letter in February. “While greater use of nonphysician personnel can improve the system, responsibility for care must be clearly defined if various personnel are to work together effectively to provide high quality services for the patient.”
TMA also urged UHC to provide further education to physicians and NPPs on proper incident-to billing.
“As part of this effort, UHC should make it clear that physicians can continue to utilize advanced practice nurses and physician assistants under proper incident-to billing arrangements, even if the advanced practice nurse or physician assistant has their own NPI,” the letter says.
TMA is setting up a meeting with UHC officials to discuss the policy, and will report on any updates in Texas Medicine Today.
For more information on incident-to billing requirements, TMA has published a questions and answers document and billing guidelines.
Optimizing Advanced Practice Providers
MGMA, October 2020
The COVID-19 pandemic has amplified the previously growing importance of advanced practice providers (APPs) in care delivery and practice performance.
Increasing demands for healthcare point to a projected physician shortage, estimated to reach between 54,100 and 139,000 physicians by 2033.1 One strategy to address this shortage is to close gaps in primary care access through increased use of APPs. One estimate points to expanded use of nurse practitioners (NPs) could reduce primary care physician (PCP) shortages by 70%.2
Many practices already recognize the substantial boost that APPs can provide to practice performance, with APP utilization growing. MGMA data show that almost 67% of Better Performer practices employ APPs; for physician-owned practices, that rate jumps to
almost 87%.3
Optimizing Advance Practice Providers, MGMA October 2020
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Delegation of Duties by a Physician to a Non-Physician, TMA, 02/2017
[embeddoc url=”https://community.poetllc.org/wp-content/uploads/2020/06/Delegation-of-Duties-by-a-Physician-to-a-Nonphysician.pdf” download=”all” viewer=”google”]
The Rising Trend of Non-Physician Provider (NPP) Utiliaztion in Healthcare, 12/2016
[embeddoc url=”https://community.poetllc.org/wp-content/uploads/2020/06/The-Rising-Trend-of-Nonphysician-Provider-Utilization-in-Healthcare.pdf” download=”all” viewer=”google”]
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