When a provider who is not yet credentialed under a particular insurance company joins a group practice, there is often a desire for the group to be able to bill insurance for this non-credentialed provider’s work. And in order to do so, it may be tempting for the group to send the claim for services as an ‘incident to’ claim, where the supervising provider’s NPI number is listed as the rendering provider’s NPI instead of the NPI number of the yet-to-be-credentialed provider.
While TherapyAppointment can help you easily create ‘incident to’ claims for a particular insurance company and set up clinical supervision, be aware that the practice of billing ‘incident to’ may not be allowed by all insurance companies and that an insurance company could even consider it a fraudulent practice that is punishable by hefty fines!
How do I determine if billing ‘adjacent to’ is legal?
- Does your insurance contract allow it? For example, Medicare may allow ‘incident-to’ billing, but private and commercial plans such as Blue Cross, Optum, etc. may not. Checking with your insurance companies is CRITICAL if you do not want to find out what prison food tastes like nor pay hefty fines that will bankrupt your business.
- Am I aware of the provider types the insurance company states are eligible for ‘incident-to’ billing in a mental health setting? Typically the only providers who are eligible to provide psychological services incident-to are:
- Doctorate or Masters level clinical psychologists
- Doctorate or Masters level clinical social workers
- Clinical Nurse Specialists
- Nurse Practitioners
- Other Masters or Doctorate level providers whose state scope of practice lists the services they are providing.
- If my insurance contract does allow it, does my clinical process qualify as ‘incident to’ services? In order to qualify as incident to, you must be able to say ‘yes’ to each of the items listed below:
- Is the supervising provider personally providing the initial assessment service?
- Is the supervising provider ordering the service and providing the treatment plan, continuing oversight of the case, and engaging the attending provider in the course of the therapy, including documented review of the notes and brief direct contact with the patient to confirm findings and evaluate the treatment?
- Is the service part of the patient’s normal course of treatment?
- Is the supervisor ‘on site’ in the office to render assistance during the session?
- Is the service provided under the ‘scope of practice’ by both the rendering provider AND the supervising provider? Realize that state scope of practice laws will generally prevail over any insurance scope of practice laws.
- Be aware that CMS is considering eliminating the ability to bill incident-to for some provider types.
The ability to bill ‘incident-to’ is certainly a tempting one to use as a group practice, but one that can have very dire consequences! A group should only proceed with creating ‘incident to’ claims after they have ensured that it is allowed in their insurance contract and that their clinical processes of supervision documentation will support a successful insurance audit.
How to set up ‘Incident to) claims in TherapyAppointment
How to set up Supervision in TherapyAppointment
Denise Hoyt, LMFT