Billing for additional complaints during the preventive examination

Is Billing “Incident To” the Right Decision to Maximize Reimbursement?

The non-physician provider “incident to” billing process can be a slippery slope if it is not correctly performed. Naturally the benefit is receiving payment at the 100% physician’s rate; however, is it worth the risk of a Medicare audit to receive the additional 15% reimbursement by billing in this manner all the time?

The decision to bill “incident to” or in the non-physician provider’s NPI is a practice decision. What works well with one practice in your area may not necessarily be the best decision for your practice. Whatever you decide, you should ensure you understand the Medicare “incident to” billing requirements, and your commercial insurance contract rules, to avoid any pitfalls.

While Medicare does have specific non-physician provider “incident to” services billing requirements, the commercial insurance company’s criteria may not be so clearly defined. It is best that you check with your respective insurance plan provider representative to better understand this process.


There are four simple criteria that must be met to fulfill Medicare “incident to” requirements:

  1. The patient must be an established patient, and the non-physician provider is following the physician’s initial diagnosis and treatment plan;
  2. Services provided must be medically necessary and appropriate;
  3. Direct supervision by the physician is required; and
  4. The physician must periodically see the patient to ensure the non-physician provider’s care is appropriate based on the initial diagnosis and treatment plan.


While the above criteria seem straight forward, it may be difficult to achieve 100% of the time in a solo physician office. As example:

  • Depending on the type of medical practice, and the number of Medicare patients, it may be impractical for the physician to see all new Medicare patients.
  • If the physician is out of the office for the day, or at a 3-day conference, does this mean the office is closed to Medicare patient appointments based on the above criteria?


If the non-physician provider has a Medicare provider number, the non-physician provider can treat both new and established patients. The downside is that their services will be reimbursed at 85% of the Medicare fee schedule. Some would argue that this is a better use of the non-physician provider’s skills, as well as the supervising physician’s time and skills.

As previously mentioned, commercial insurance plans may not follow Medicare guidelines. In fact, some commercial insurance plans may not separately credential non-physician providers, and the “incident to” criteria do not have to be met. In these cases, the claim would be billed out under the physician’s NPI and the claim should be paid at the 100% reimbursement level.


We understand with reimbursement levels as they are, some practices may decide to bill all claims as “incident to”, but there is risk involved, such as:

  • The front desk staff may schedule a new Medicare patient to be seen by the non-physician provider, and the billing staff may not catch this error before sending the claim to the clearinghouse.
  • The non-physician provider may be treating an established patient, and the patient presents a new problem during the encounter.
    An audit identifies that the supervising physician was not physically in the office on several dates when “incident to” services were billed.


All of the above risks can be eliminated by ensuring the non-physician provider is credentialed with Medicare, as well as those commercial plans who do credential non-physician provider. Still confused?


Contact Concordis today for a consultation



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