MedPAC considers direct Medicare billing for NPs, PAs

The Medicare Payment Advisory Commission, an independent federal agency that advises Congress on Medicare, is considering a recommendation to eliminate "incident to" billing for nurse practitioners and physician assistants, effectively swapping a 100 Medicare reimbursement rate for one that is 85 percent of Medicare's fee schedule.

Nurse practitioners and physician assistants currently bill "incident to" services, such as evaluation and management visits, using the physician's CMS-issued unique 10-digit identification number, known as a national provider identifier. Reimbursement for "incident to" billing is 100 percent of the Medicare fee schedule. However, nurse practitioners and physician assistants cannot use "incident to" billing in certain circumstances, such as for new patients in a hospital setting or for a new issue for an existing patient.

The recommendation being considered by MedPAC would eliminate "incident to" billing, and nurse practitioners and physician assistants would bill Medicare directly, with reimbursement at 85 percent of the Medicare fee schedule.

During a Dec. 6 presentation, MedPAC staff told commission members Medicare claims don't show when a service is billed "incident to," and MedPAC analyses suggest "a substantial share of services" that nurse practitioners and physician assistants perform are billed "incident to."

MedPAC staff told commissioners there are problems with "incident to" billing" because it "obscures policymakers' knowledge of who is providing care for beneficiaries," "inhibits accurate valuation of fee schedule services," and "increases Medicare and beneficiary spending." Staff also said that physician assistants and nurse practitioners increasingly practice outside of primary care.

MedPAC commissioners will vote on the recommendation issue in January.


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