In a recent program for the American Health Law Association, Thompson Coburn partner Milada Goturi co-presented on “Navigating Billing and Compliance Issues for Advance Practice Professionals.”
With increased demand for services of nurse practitioners and physician assistants, commonly referred to as Advance Practice Professionals (APPs), health care providers need to stay up to date on billing and compliance considerations when using those professionals.
Rising patient volumes and physician shortages, coupled with increasing costs and decreasing reimbursement, have set the stage for continued growth in APPs’ services. The benefits include improved access to care, better patient and provider satisfaction, efficiency and cost savings. Along with that, however, comes the increased importance of key billing and compliance considerations. Those include:
- Compliance with Medicare billing requirements and use of correct billing method depending on practice setting
Medicare billing methods for services of APPs include direct billing, incident-to billing, and split (or shared) billing. Each has its own requirements and limitations – for example, with incident-to billing, services cannot be used in a hospital setting, while split (or shared) billing is not allowed in a physician office setting. Being aware of the limitations of each method can help avoid enforcement actions. Private payors may or may not follow Medicare billing requirements.
- Compliance with state professional licensure laws
There are many variations in state law when it comes to services of APPs. For example, some states provide for full practice authority, while others require the APP to work under a physician’s oversight. To align a practice with legal requirements, providers need to evaluate factors under their relevant state laws including:
- Whether provider teams are set up not to exceed the number of APPs a physician may collaborate with.
- Whether a physician is reviewing the required number of APP’s charts/medication records and correctly documenting those reviews.
- Whether on-site physician presence requirements are met.
- Compliance with hospital licensing requirements, Medicare conditions of participation and accreditation requirements
State hospital licensing requirements, Medicare conditions of participation and accreditation requirements need to be considered when structuring services of APPs, as each may impose specific standards applicable to their services.
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