MEDPAC calls for end to 'Incident to' billing

“Incident to” billing by advanced practice registered nurses (APRNs) and physician assistants (PAs) would be eliminated if Congress adopts a recent recommendation from the Medicare Payment Advisory Commission (MedPAC).

In its June quarterly report to Congress, MedPAC suggests requiring APRNs and PAs to bill Medicare directly for all their services, rather than under the national provider identifier of a supervising physician, or “incident to”.

The report notes that the “incident to” billing rules were established well before the growth both in the numbers of APRNs and PAs and their importance in the healthcare system. That makes it increasingly important to differentiate the services they provide from those provided by physicians.

The information made available through direct billing “could create substantial benefits for the Medicare program, beneficiaries, clinicians and researchers that range from improving the accuracy of the physician fee schedule [to] reducing expenditures, enhancing program integrity, and allowing for better comparisons between the cost and quality of care provided by physicians and APRNs/PAs,” according to the report.

MedPAC estimates that implementing the recommendation would reduce Medicare spending by $50 million to $250 million in the first year and $1 billion to $5 billion over the first five years, as compared to current law. That’s because services APRNs and PAs bill under a physician’s provider number are reimbursed at 100 percent of Medicare’s physician fee schedule rate, while those billed under their own provider number are  reimbursed at 85 percent of the PFS.

Joyce Knestrick, PhD, FAANP, president of the American Association of Nurse Practitioners, applauded the recommendation. “We urge Congress to act on this recommendation as soon as possible,” she said in a written statement.

The MedPAC report also recommends that Medicare refine its specialty designations for APRNs, PAs and clinical nurse specialists (CNSs) to distinguish between those working in primary care versus other specialties.

It notes that for a variety of Medicare programs and objectives, such as attributing beneficiaries to Accountable Care Organizations, Medicare generally considers all nurse practitioners (the largest subset of APRNs), PAs and CNSs to be primary care providers. But “because of the shifts in specialty selection over time for NPs and PAs, this assumption increasingly inhibits Medicare’s efforts to identify and support clinicians furnishing primary care.”