Incident to Billing in Healthcare

Incident to Billing

• Allows supervising physicians to be reimbursed for 100% of the billed amount, compared to 85% for independent NPs.
• Reinforces the hierarchy in healthcare by implying NP care is inferior and requires physician oversight.
• NPs' contributions become invisible as all services are billed under physicians' NPI numbers, hindering Medicare's ability to recognize NP services.

Third-Party Payer Categories

• Seven general categories: Medicare (A, B, C, D), Medicaid, indemnity insurance, managed care organizations (MCOs), workers' compensation, Veterans Administration, and auto liability.
• Includes those without health insurance, termed private pay, who often face significant financial constraints.
• Each payer has distinct policies, but all adhere to CMS guidelines for health care delivery and reimbursement.

Medicare and NPs

• Nonphysician practitioners, including NPs, received billing approval from CMS through the Balanced Budget Act of 1997.
• NPs typically receive 85% of the physician's fee under Medicare, with patients responsible for a 20% co-payment.
• Medicare Part A involves hospital services with specific out-of-pocket costs for various lengths of stay, and the deductible was $1,484 in 2021.
• Medicare Part B covers outpatient services, with a yearly deductible of $203 in 2021.

Medicaid Overview

• Jointly funded by federal and state governments to provide assistance to low-income individuals and families.
• Eligibility includes children, pregnant women, parents, seniors, and individuals with disabilities, determined by Modified Adjusted Gross Income (MAGI).
• States opting for Medicaid expansion saw significant financial benefits due to increased federal funding.

Diagnostic Process

• OLD CART method identifies patient symptoms: onset, location, duration, characteristics, aggravating/relieving factors, and treatment.
• CSOC outlines essential components for understanding a patient’s chief complaint and establishing rapport.

Healthcare Power of Attorney and Living Wills

• A healthcare POA designates someone to make medical decisions when a patient is unable, functioning alongside a living will.
• A living will outlines specific treatment preferences, organ donation desires, and end-of-life care options.

Ethics in Healthcare

• Ethics is defined as determining what ought to be done, especially in bioethical dilemmas.
• ANA's code of ethics highlights the importance of patient commitment, rights advocacy, professional integrity, and health improvement.
• Key ethical principles include autonomy, beneficence, nonmaleficence, veracity, confidentiality, fidelity, and justice.

Malpractice Considerations

• Essential elements include the duty to the patient, deviation from care standards, and resultant harm.
• Two insurance policies:
  • Claims-based covers incidents only during active coverage.
  • Occurrence-based covers incidents regardless of current insurance status.

Reimbursement Challenges for APRNs

• Unequal pay persists in Medicare and Medicaid practices, with significant implications for NP financial viability and practice authority.
• Mandated LACE requirements (licensure, accreditation, certification, education) for APRN standards of practice establish pathways for qualification and employment.

Teleological vs. Deontological Ethics

• Teleological ethics focus on the consequences of actions, aiming for the greatest good.
• Deontological ethics, stemming from Immanuel Kant, emphasizes duty and moral rules as guides for ethical behavior.

Healthcare Payment Models

• Medicare Advantage (MA) plans provide various coverage options but have faced sustainability challenges.
• Beneficiaries face higher costs for non-covered and out-of-pocket services, impacting access to care.

This quiz explores the concept of incident to billing, which allows supervising physicians to receive full payment for services rendered by nurse practitioners (NPs). It discusses the implications for NP practice, the perception of care quality, and the hierarchical nature of this billing method. Test your understanding of the advantages and drawbacks of incident to billing in healthcare settings.