Incident-to billing is a Medicare billing mechanism applying strictly to the outpatient, office setting.  It does not apply to hospital-based outpatient clinics (POS 22) nor does it apply to hospital inpatients.  The incident-to rules permit a physician to bill under her own national provider identification (NPI) number for the services of non-physician mid-level providers as if the physician performed those services herself.    To be covered on an incident-to basis, the services must meet the myriad of Medicare rules that can be onerous and difficult to operationalize.  Moreover, the OIG has targeted incident-to claims in its 2013 work plan.   If you are in an office setting (POS 11) and would like to bill Medicare “incident-to” we ask that you have a policy in writing meeting Medicare’s incident-to requirements.  Please contact our office for details.

However, the vast majority of our clinics are hospital-based (POS 22), and therefore Medicare’s incident-to rules to not apply.  This means that if mid-level providers are seeing Medicare/ Medicare HMO patients in the clinic, they must bill under their own NPI.  There is no “incident-to” mechanism available in POS 22 for Medicare/Medicare HMO patients.

Submitting incident-to claims to Medicare that do not meet the rules is considered to be potentially false claims.  Such claims are punishable by the DOJ and the OIG for up to $11,500 per claim plus triple the charges if it is determined that the physician should have known the rules.  Since the financial implications can be significant and even possibly lead to criminal punishment, although unlikely, please ensure that everyone in your clinic understands that if a mid-level provider is seeing Medicare patients alone (without the supervising physician) in our provider-based clinics, they must bill under their own NPI.   Please contact our office with any questions.

Nicole Almiro