WASHINGTON — A group of expert policy advisors to the Secretary of Health and Human Services voted unanimously to recommend jettisoning “incident to” billing for advanced practice registered nurses (APRNs) and physician assistants (PAs) in Medicare, during a meeting on Thursday.
Under current Medicare rules, these mid-level clinicians can bill services as “incident to” physician services using the physician’s national provider identifier (NPI) or they can bill Medicare directly under their own NPI.
However, if a new recommendation from the Medicare Payment Advisory Commission (MedPAC) is adopted, the “incident to” option would be scrapped and APRNs and PAs would only bill Medicare directly for all the services they provide.
Medicare pays 85% of the fee schedule amount when these mid-level clinicians bill the program directly, while services billed as “incident to” are paid at 100% of the fee schedule amount.
The recommendation would save the program money — approximately $50 to $250 million annually and just under $1 billion over 5 years, MedPAC’s technical staff said.
“It really masks the true impact of the reliance of the healthcare system on nurse practitioners (NPs), said Joyce Knestrick, PhD, president of the American Association of Nurse Practitioners (AANP), speaking on “incident to” billing in a phone interview, during which a press representative was present.
“We know that we provide about a billion visits per year, but we can’t count all the ones that are ‘incident to’ billing,” she said. “This … undermines the foundation of value-based reimbursement.
When NPs services are billed as “incident to” they can’t meet the low-volume threshold of Medicare’s Merit-based Incentive Payment System (MIPS). For example, under 2018 rules, MIPS required participants to report more than 200 Medicare Part B beneficiary visits to be eligible for the program.
In cases where a practice has a bonus system based on the MIPS, “the NP would not get anything and the other providers would get all the incentives,” Knestrick added.
Asked whether she was concerned about MedPAC’s projection that the recommendation could cause a decline in revenues for some practices that employ APRNs and PAs, Knestrick said she believed the difference could be offset by an increase in value-based payments.
The number of NPs and PAs billing Medicare has mushroomed in the last several years. And the number of NPs specifically who bill Medicare has more than doubled, from 52,000 to 130,000 from 2010 to 2017, MedPAC’s technical staff noted. The number and variety of services NPs and PAs perform has also grown, they said.
In explaining the rationale behind the recommendation, prior to the vote, MedPAC’s technical staff highlighted that “incident to” billing limits transparency and prevents “accurate valuation” of services, while billing Medicare directly would bring more clarity and accuracy to Medicare data.
Staff also projected that the recommendation would reduce beneficiary spending, without negatively impacting their access to care.
In addition to recommendations around direct billing, MedPAC also voted unanimously to “refine” Medicare’s specialty designation for APRNs and PAs. One way to implement this would be to have APRNs and PAs report their specialty at the same time they enroll as providers in the Medicare program.
During the meeting on Thursday, Commissioner Marjorie Ginsburg, MPH, of Sacramento, California, said she understood that having mid-level providers bill under a physician’s NPI could be “mucking up” data around with which provider to attribute services to, but she wondered aloud whether it was possible to draw a distinction in the reporting between the provider who performs the service and the way the care is billed.
Ginsburg conceded she had concerns about retiring “incident to” billing for primary care, “for financial reasons.”
“We’re all struggling with ‘how do we maintain adequate income for primary care physicans,’ and if they’re possibly making a little money by hiring NPs to do the work … that may not necessarily be a bad thing,” she said.
In response, Kate Bloniarz, a senior analyst for MedPAC, confirmed that it was possible to separate the attribution of service from payment.
“You could have a performing provider, a rendering provider, a billing provider — have it all be separate and have the payment amount be attached to one of the other categories,” Bloniarz explained.
But, Brian O’Donnell, MPP, interjected, if the goal is to boost funding for primary care, “this is a really inefficient way to do it.”
Only about half of NPs practice in primary care and only a quarter of PAs do, according to MedPAC’s technical staff. Knestrick noted that around 86% of NPs report working in primary care. However, she suggested the discrepancy could be due to differences in how primary care is defined.
However, the second recommendation, refining specialty designations, could help to identify those NPs who work in primary care and, if adopted, allow the commission, in the future, to recommend directing more money toward that particular group of NPs.