Extend Your Reach with Nonphysician Providers– January 31, 2017

Most physicians are stretched to maximum capacity in terms of time and effort devoted to their patients — and often, it still isn’t enough. One way to improve patient services and increase patient satisfaction is to hire nonphysician providers (NPPs) to fill in the gaps.  

Two Categories

There are two primary categories of NPPs: physician assistants and nurse practitioners. Which category is best for your practice depends on which is licensed in your state and the range of activities the NPP being considered is licensed to perform.
 
An NPP may be able to function independently or work under a doctor’s supervision — again, depending on relevant state law. Typical services that an NPP of either type may provide include:

  • Coordinating health education, patient counseling and patient care,

  • Ordering and/or performing diagnostic and therapeutic procedures,

  • Arranging patient referrals,

  • Delivering on-call care,

  • Performing physical exams,

  • Taking patient histories, and

  • Contributing to clinical decision making.

Discuss with your physicians which services they’d be willing to accept from an NPP. Also, calculate the appropriate number of NPPs to meet the practice’s needs, and establish benchmarks to evaluate NPP performance.

Likely Candidates

The most direct way to find good NPP candidates is through job listings on the websites of local and national associations for physician assistants and nurse practitioners. (Check out https://www.aapa.org for the American Academy of Physician Assistants and https://www.aanp.org for the American Association of Nurse Practitioners.) Another source of candidates may be local schools that train NPPs.
 
Once you’ve found and hired your NPPs, you’ll need to introduce them to two critical constituencies: physicians and patients. When introducing them to doctors, clarify how the NPPs will improve patient care. Next, define the roles for physicians and NPPs and document applicable standing orders, protocols, collaborative agreements and supervision agreements. Also send letters to patients explaining the hire of NPPs and the role they’ll play.

Medicare Considerations

An NPP can bill Medicare for services in two ways:

  1. “Incident to” a physician’s care, using the doctor’s National Provider Identifier (NPI), or

  2. Directly after being credentialed by Medicare, using the NPP’s own NPI.

Under the first option, after an initial visit by a doctor, the NPP can provide services under the physician’s direct supervision or while the doctor is available in the office to give immediate assistance. To continue billing subsequent visits with the NPP as “incident to,” the physician must actively participate in and manage the patient’s treatment, with commensurate documentation in the patient’s medical record.
 
Unless all of an NPP’s services fall within the “incident to” definition, the NPP must use the second option — that is, to enroll in Medicare, obtain an NPI and bill directly. NPPs who bill directly receive lower reimbursements than when they bill “incident to.” It’s 85% of the full physician fee schedule rate vs. 100%.

The Commercial Payer Side

Private commercial payers have their own rules about reimbursing NPP services. They usually apply separate criteria for credentialing NPPs, sometimes not allowing them to bill directly.
Plus, they typically reimburse NPPs at lower rates than for supervising physicians. Your practice must bill under the doctor’s NPI and follow the billing guidelines in the payer’s provider manual. And you may need to append certain modifiers to the bill to correctly identify the NPP and supervising physician providing the care together.

An Extra Hand

Failure to satisfy the billing requirements of either Medicare or a private payer can create serious compliance problems for a practice. Regularly consult the websites of the Centers for Medicare and Medicaid Services and relevant private insurers to stay up to date on NPP billing rules.
 
NPPs aren’t right for every practice. But if handled well, they can serve both patients’ and physicians’ needs, leading to better allocation of therapeutic resources. For busy physicians in a growing practice, NPPs are a viable option to consider in their efforts to improve patient care.
 
Contact Kathy Walsh at kwalsh@cohencpa.com for more information.
 
Cohen & Company is not rendering legal, accounting or other professional advice. Any action taken based on information in this blog should be taken only after a detailed review of the specific facts and circumstances.