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There are now 200,000 new targets for CMS and private payers.

Since the first of this year, I have engaged in several audits for which the target is not the physician, but rather a physician’s assistant (PA) or a nurse practitioner (NP). While there have always been audit issues regarding the use of incident-to and split/shared services, the focus was usually the physician provider and not the non-physician practitioner (NPP). But this is obviously changing.

Why the concern? Well, physicians alone provide nearly a million targets for the Centers for Medicare & Medicaid Services (CMS) and private payer audits, which seems like enough to keep them busy for the next few decades. But add in another couple of hundred thousand NPs and PAs, and target acquisition becomes that much richer; and in their minds, so do the auditors. But first, a bit of background.

The use of NPPs in medical care has been a generally accepted model since the physician shortage of the 1960s. In particular, I am talking about the inclusion of PAs and NPs. Part 3 of the Medicare Carriers Manual (MCM) touches on PA services (section 2156) and NP services (section 2158), and there is little doubt among healthcare professionals as to the value they add to the overall efficiency and quality of care for a provider organization. Way back in the day, I spent several years as a PA before trading in my stethoscope for a calculator, and in my humble opinion, a well-trained and qualified PA could do 80 percent of what a physician can do. I know that is not universally accepted, but it is my opinion and personal experience.

CMS has a bunch of rules and guidelines regarding what NPPs can do and how they are to be paid. This includes the controversial differences between incident-to and non-incident-to services, as well as the rules surrounding shared/split services. While this article is not about those policies per se, it is important to at least understand the basic differences between them.

In general, the MCM states that if basic requirements are met, Pas and NPs may be covered under Medicare Part B payments. Incident-to is defined as “those services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home. To qualify as ‘incident to,’ services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment.” (MLM Matters Number: SE0441)

From a reimbursement standpoint, incident-to services are paid less than if the NPP were to perform those services not incident-to. Under most circumstances, they are paid at around 85 percent of what would have been paid had a physician performed the service.

A split/shared service is a bit different from an incident-to service, both in requirements and payment. Medicare Part B defines a split/shared E/M visit as “a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service.” Split/shared services are paid at the physician rate of the E/M code; however, the payment is singular, and based on the combined efforts and documentation of both the physician and the NPP.

I probably should have stated this earlier, but I am not an expert on NPP policies, rules, laws, or billing requirements. I am, however, an expert on audits and audit risk, and I am confident in the shift that I am seeing take place: auditors going from targeting just physicians to targeting physicians and NPPs. For example, in one of the audits in which I was engaged this year, the focus was on evaluation and management (E&M) codes submitted by the NP using their NPI number. It really wasn’t much different than I would have expected for a provider, but in the past, at least from my experience, it appeared that NPs were immune from targeting. Another audit involved a PA and included both E&M and AS modified procedures. Again, in the past, it would have been the physician that was the most likely target, but in this case, the primary target was the PA.

Some years ago, I read a great article titled “Can NPs and PAs Fill the Primary Care Gap?” written by Ben Hartman of MedPage Today (Sept. 17, 2013). I know the article is a bit dated, but the concerns for the future were spot on. Of particular interest is a quote by Fitzhugh Mullan, MD of George Washington University School of Health Sciences. He stated the following: “over time, I can’t think of any reason the overall attitudes, proclivities, problems, and successes won’t be similar to those of physicians.”

In context, Dr. Mullan was referring to the movement away from primary care to specialization; however, I would expand that to the audit risk issues that have faced physicians for what seems like forever. Physicians face these myriad administratively complex sets of rules and regulations, and NPPs are not immune from any of them. In fact, there are even more rules and regulations that apply to them, so I would opine that their risk is even higher, although it has not been realized until recently.

In an article published by RACmonitor on Sept. 28, 2017, Shannon Deconda, founder of NAMAS and a partner in Doctors Management, LLC, noted how UnitedHealthcare (UHC) now requires physicians “reporting E/M services on behalf of their employed advanced practice healthcare professionals to report services with a modifier to denote the service were provided in collaboration with a physician.” The crux of the article was about the possibility of this change causing denials of submitted claims, but in my paranoid, conspiratorial mind, it is nothing more than a more sophisticated tracking mechanism to allow UHC to specifically target the NPP along with the physician provider.

The bottom line is that there are now 200,000 new targets for both CMS and private payers’ auditors to go after with respect to recoupment and recovery audits. I believe we will continue to see an increase in the number of incident-to and shared/split services audits. At least in my experience, that isn’t in question. But what I also expect to see this year is an increase in audits that have typically been associated with providers encapsulating the NPP arena. As such, it is the wise compliance officer that begins to treat their NPPs just like they treat their physicians. From my perspective, we have tweaked our algorithms to account for NPPs just as we would for physicians, and from the perspective of risk-based auditing, everyone else should be doing the same.

It was Giovanni Torriano who first coined the phrase, “to go about to fetch blood out of a turnip.” Somewhere around 1788, Vicesimus Knox changed that to “it is impossible to get blood out of a stone.” I agree with both, but that is not going to stop payers from trying.

And that’s the world according to Frank.


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Frank Cohen

Frank Cohen is the director of analytics and business Intelligence for DoctorsManagement, a Knoxville, Tenn. consulting firm. He specializes in data mining, applied statistics, practice analytics, decision support, and process improvement. He is a member of the RACmonitor editorial board and a popular contributor on Monitor Monday.

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