UnitedHealthcare’s Modifier SA: Audit Problems Are Lurking

UHC bulletin excerpt underscores necessity of close scrutiny.

In the June 2017 UnitedHealthcare (UHC) network bulletin, there was an article that addressed UHC’s decision to no longer pay for consult services. We addressed this in previous audit tips and articles created by our team, but the other issues that must be addressed involve the small print on that same page, buried in a color bordering. The following is an excerpt:

“New Policy – Advanced Practice Health Care Professional Evaluation and Management Procedures Policy: Effective for claims with dates of service on or after Sept. 1, 2017, UnitedHealthcare will require physicians reporting evaluation and management (E/M) services on behalf of their employed Advanced Practice Health Care Professionals to report the services with a modifier to denote the services were provided in collaboration with a physician. UnitedHealthcare will accept the modifier SA on claims for these services when provided by nurse practitioners, physician assistants, and clinical nurse specialists. In addition, the rendering care provider’s National Provider Identifier (NPI) must also be documented in field 24J on the CMS-1500 claim form or its electronic equivalent. Use of the modifier SA and documentation of the rendering care provider will assist UnitedHealthcare in maintaining accurate data with regard to the types of practitioners providing services to our members.”

Will this cause claims denials? At first blush, it appears the answer is no – this more likely would be an issue noted on claims review. The guidance indicates that UHC will require physicians who are billing for an encounter on behalf of their NP/PA to use the SA modifier. Therefore, it would seem that if your qualified healthcare professionals are credentialed through UHC, the modifier is not required when billing those services (and actually, adding the modifier to these services actually could cause claims denials).

In a healthcare era of data mining and benchmarking, RVUs billed and time billed per NPI should be all a carrier would need to identify a potential incident-to billing practice. However, by incorporating a mandatory use of a modifier (SA), they are now requiring organizations to bring attention to services billed as incident-to.

Therefore, you must ensure that your organization is appropriately reporting incident-to services. Many practices stand resolute on the idea of reporting their qualified healthcare professionals under the incident-to provision. And look, with the continued reduction in reimbursements, willingly giving up 15 percent on each service performed by these professionals is one heck of a cut! Healthcare is turning into an industry in which risk tolerance must be analyzed with each endeavor. This change is no different. The stringent rules governing incident-to services do not make it impossible, but rather cumbersome, to ensure accuracy of meeting the relevant requirements on each and every visit.

Let’s follow the Centers for Medicare & Medicaid Services (CMS) Incident-to Guidelines (the gold standard, if you will), the “main rules, according to CMS guidance,” and relate these to the impact of claims being reported with the SA modifier:

  • The supervising physician must be on-site: Performing a simple cross-referencing of claims billed under a given supervising physician, with claims reported under his or her NPI with a SA modifier, would be a good indication of whether the supervising physician was active in a clinic on a given date of service. Now, posing as devil’s advocate, could the supervising physician be on-site even if there were no billed services? Absolutely, but again, we are exposing what additional risks for audit to which an organization will now be susceptible.
  • No new patients should be billed incident-to: Well, of course this one is easy, and I would presume that UHC may actually incorporate edits that automatically deny new patients, consults, and any initial patient E&M services billed with a SA modifier.
  • No new problems for established patients: By analyzing new diagnoses reported for a patient on a claim incorporating the use of a SA modifier, UHC would be able to reasonably suspect claim reporting errors relevant to this incident-to criterion. Now there is controversy within the world of incident-to regarding the proper use of split-shared services in these instances, and we could spend an entire article discussing this topic, but regardless of that, these claims may now be further recognized, acknowledged, and scrutinized due to the use of the modifier.

While those are the big rules of incident-to, an inappropriate practice of incident-to may also be detected by highlighting these claims as incident-to with the SA modifier. Let’s use an example to better explain this example of inappropriate use.

Consider a case in which an 86-year-old patient comes into the office for follow-up of her chronic diabetes. Oh, by the way, she notes, I have new onset of back pain – we now have an established patient with a new problem. For the savvy practice, adhering and meeting incident-to guidelines, this is no problem: they will merely bill that encounter out under the qualified healthcare professional’s NPI number for that encounter. But herein lies the problem. When this patient comes back next month and she sees a qualified healthcare professional for follow-up, we still do not have a plan of care that has been created by the supervising physician. So, the reality is that after the patient was seen, she should have been scheduled for follow-up with the supervising physician to then create a plan of care that could be used under the incident-to criteria.

UHC now will have the ability to track these new diagnoses to encounters with a SA modifier to create audit plans, which creates data mining (relevant to incident-to) of a much higher complexity.
This should actually spur some thoughts of “Hmm, I wonder why UHC is requiring the use of the SA modifier all of a sudden?” That would be a great question, and we would love to hear input from any UHC/OPTUM representatives that could provide opinions on this. We could speculate that it is being requested in an effort to create an easier way for the carrier to track and monitor services being billed under the incident-to provisions, and we have certainly noted the impact this will have.

Be prepared to go back through your September 2017 cases and correct billing as needed for all of your nurse practitioner, physician assistant, and clinical nurse midwife services. As claims reviews continue in sweeping numbers, your at-risk claims become liable for UHC takeback initiatives.

The golden ticket to this change is to make sure that you are utilizing incident-to services properly. By having an active compliance plan in place that includes an auditing and monitoring plan, we should be analyzing our billing, coding, and documentation on an ongoing basis – and ensuring that we are prepared and ready to have an audit performed at any time.

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Shannon DeConda CPC, CPC-I, CEMC, CMSCS, CPMA®

Shannon DeConda is the founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the president of coding and billing services and a partner at DoctorsManagement, LLC. Ms. DeConda has more than 16 years of experience as a multi-specialty auditor and coder. She has helped coders, medical chart auditors, and medical practices optimize business processes and maximize reimbursement by identifying lost revenue. Since founding NAMAS in 2007, Ms. DeConda has developed the NAMAS CPMA® Certification Training, written the NAMAS CPMA® Study Guide, and launched a wide variety of educational products and web-based educational tools to help coders, auditors, and medical providers improve their efficiencies. Shannon is a member of the RACmonitor editorial board and is a popular guest on Monitor Mondays.

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