For Practice Success, Know Thy Biller!

Physician and non-physician healthcare practitioners are increasingly working side by side these days, especially in integrative and holistic clinics.

While the myriad benefits of offering integrated team-based care are clear, the management of diverse teams of health professionals also poses some administrative and financial challenges.

In insurance-based practices, billing for services is one of those challenges. Failing to bill for time and services provided by non-physician staff, or doing so incorrectly, puts practitioners at risk for denied or delayed claims payments and missed reimbursement opportunities for services offered.  

Some integrative clinics have found “incident-to” billing strategies to be an effective way of making the interdisciplinary model work on a financial level.

LundquistFoxAt Holistic Primary Care’s recent 2015 Heal Thy Practice conference, Dr. Erik Lundquist, co-founder of the Temecula Center for Integrative Medicine (TCIM) in Temecula, CA, discussed the advantages of incorporating incident-to services into an insurance-based integrative practice.

From a payment perspective, the Medicare system covers a variety of integrative practitioners by reimbursing physicians for services provided “incident to” the physician’s care (Gosfield, A. Fam Pract Manag. 2001; 8(10): 23-27). This has been true for many years. The issue, says Dr. Lundquist, is that doctors are not generally well schooled in how to take advantage of this option.

As defined by the Centers for Medicare and Medicaid Services (CMS), incident-to services are those that are “furnished incident to physician professional services in the physician’s office.”

The services must be offered in a “non-institutional setting,” identified as any location other than a hospital or skilled nursing facility, “such as a separate office suite, within an institution, or in a patient’s home.”

To qualify as incident-to, the services must be verifiably integral to a patient’s normal course of treatment, and must also be an incidental part of their physician’s overall care.

Even if non-physicians will carry out ongoing services, a doctor must personally perform the initial service and remain actively involved throughout the patient’s ongoing treatment.

Medicolegally, that’s a very important point. Incident-to billing is not a license for absentee doctoring.

While physicians don’t have to be physically present in the treatment room when incident-to services are conducted, they are required to provide direct supervision and “must be present in the office suite to render assistance, if necessary.” Additionally, the essential reasons and requirements for incident-to services must be clearly documented in patient records.

Many clinicians see incident-to services as an attractive option because both doctors and other qualified non-physicians — including physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, and clinical psychologists — can receive complete payment for services rendered.

Repayments are based on the Medicare physician fee schedule and are billed to carriers as Part B services as if a physician personally provided them.

But Dr. Lundquist stressed that the key to getting paid for incident-to services, is to carefully follow guidelines set forth in the Medicare Benefit Policy Manual.

Advantages of Incident-To Billing

Lundquist noted that by offering additional services via ancillary practitioners at his clinic, he is able to better leverage his time — and ultimately spend more of it working directly with patients.

When patients can access a range of services at one location, doctors no longer have to act as jugglers of their patients’ care. They can instead focus on their primary responsibilities of seeing patients and helping them to create individualized treatment plans.

In an interdisciplinary collaborative setting, doctors are less likely to become burned out, he added, and can devote more time to longer office visits with their patients.

Additionally, collaborative practice removes from doctors the burden of having to be the clinic’s sole financial engine. A collaborative model spreads fiscal expectations and responsibilities across a larger team and creates multiple funding streams.

Know Thy Biller

When incorporating incident-to services into a medical practice, Lundquist stressed the importance of keeping meticulous records. From a billing standpoint, a doctor’s treatment plan must be not only justified, but also well.

TCIM co-founder Nikki Fox, who also presented at Heal Thy Practice alongside Lundquist, encouraged clinicians to seek out billers who have a solid understanding of incident-to services and requirements.

This is a critical piece of advice: incident-to claims that don’t meet Medicare requirements can be considered false claims, and the financial and criminal penalties for fraudulent claims are potentially devastating.

Not all billers are the same, Fox stated, and it’s crucial that practitioners align with billers who share their values. She and Lundquist view their billers as key elements of their clinic, working in partnership to audit practitioners’ coding, make decisions about what’s best for the business, and help ensure that all possible ancillary services are covered.

They offered the following touchstones for evaluating billers:

1. Willingness to Work: Making sure the biller is willing to actually “work” for you. “Most billing companies that we interviewed were more interested in getting our business than working for us.”

2. Understands Holistic Medicine: Integrative/holistic practice has many nuances, make sure the biller understands them. “One of the executives for our current billing company had been a patient for an integrative physician so she “gets” it.”

3. Represents Your Practice Well: Your biller will be an extension of your practice. Make sure the biller shares and reflects your values. “Both our previous billing company and our current one make sure that they give our patients the same kind of attention and help that we give to patients in the office.”

4. Accuracy & Timeliness: Make sure that you get accurate and timely reports of all your billing.

Ms. Fox noted that via her consulting service, Integrative Medicine Consulting Group, she is happy to help other practitioners try to find billers who are in alignment with the values of holistic medicine. Reach her at: or 858-877-0305.

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