decisionhealth Newsletters, Coder Pink Sheets - 2006 Issue 4 (April)
No incident-to in private payer worlds
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Article Overview
This article reviews how the concept of incident-to applies in Medicare but not in the same way for private payer billing. It is aimed at pediatricians, practice managers, and coding professionals who bill services furnished by nurse practitioners, physician assistants, and other nonphysician providers. The discussion focuses on payer credentialing, claim submission under different provider names, supervision expectations, and the need to compare state scope-of-practice rules with individual insurer policies and contracts.
Why This Topic Matters
Billing rules for nonphysician provider services can differ substantially across payers, and misunderstanding those differences can affect claim submission, credentialing, and compliance. The article helps readers recognize where private payer policies may align with or diverge from Medicare and why practice-specific verification is necessary.
What You Will Learn
- How private payer billing for nonphysician provider services differs from Medicare concepts
- Why credentialing and claim submission rules matter when billing under an NPP
- How state scope-of-practice law and insurer policy can affect supervision requirements
- Why practices should verify payer-specific rules before submitting claims for NPP services
Who Should Read This
- Pediatricians
- Practice managers
- Medical coders
- Billing staff
- Nonphysician providers
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