Medicare Reimbursement Regulations, Case Study Example

Incident to billing is a form of billing for outpatient services that are not provided by a physician; rather, they are provided by a nurse practitioner, physical therapist, or other non-physician role (Stantz, 2013). This type of billing was established by the Center for Medicare and Medicaid Services (CMS) to ensure that non-physician professionals could bill for their services without the approval of a physician (Stantz, 2013). This is an important option for healthcare professionals to properly bill for the services that they have rendered to patients in the outpatient setting (Stantz, 2013). Advanced practice nurses must meet a number of requirements before they are eligible to bill for their services through Medicare, such as certification through a number of organizations and licensure within the states where they reside (Frakes and Evans, 2006). However, in order to obtain maximum reimbursement for these services, they must be billed with prior physician approval (Frakes and Evans, 2006).

In order to maximize the level of reimbursements that are received, organizations must utilize a number of different payers that will provide revenue and enable them to stay in business (Healthcare Finance News, 2014). Therefore, it is important to utilize a variety of payers so that billing will occur on a consistent basis and reimbursements are maximized as best as possible (Healthcare Finance News, 2014). These efforts support the ability of organizations to bill through payers such as Medicare, private insurance, Medicaid, and third party services, all of which require some degree of compromise and balance so that reimbursement rates are competitive and consistent with those required throughout the industry (Healthcare Finance News, 2014). This practice will attract many different types of payers to collaborate with the organization in order to provide services, and will enable organizations with the highest level of quality to provide service under the umbrella of many different types of reimbursement structures (Healthcare Finance News, 2014).

References

Frakes, M.A., and Evans, T. (2006).An overview of Medicare reimbursement regulations for Advanced Practice Nurses. Nursing Economics, 24(2), 59-65.

Healthcare Finance News (2014). Healthcare finance index. Retrieved from http://www.healthcarefinancenews.com/directory/reimbursement

Stantz, R. (2013). Demystifying Medicare’s ‘incident to’ billing by nurse practitioners, physician assistants. Retrieved from http://medicaleconomics.modernmedicine.com/medical-economics/news/demystifying-medicares-incident-billing-nurse-practitioners-physician-assista