Q: Can physicians bill Medicaid for services provided by an NP?
A nurse practitioner in a rural school-based clinic asked if she could bill Medicaid for her services under her collaborating physician's name. She wishes to bill under the physician's name because this allows the clinic to receive 100% reimbursement for her services versus 92% if she bills under her own name as an APN. For APNs that work in medically underserved areas or in sites serving a medically underserved population, the answer would be the same.
A: Yes, as of August 2006, the services a NP provides in a school-based clinic could be billed under the physician’s name if the physician uses an SA modifier. However, it should be noted that the Health and Human Services Commission rule, 1 TAC §354.1062(e), that permits this practice may change as the rule is scheduled to be revised in late 2006. Until that new rule is adopted, the following answer still applies.
Health & Human Services Commission (HHSC) allows physicians to bill Medicaid for services provided by an advanced practice nurse or physician assistant in both inpatient and outpatient settings. The Tile 1 TAC §354.1062 (e) specifically states that the physician does not need to be on site at the time the service is provided, and that an APN is exempt from the supervision required of a physician who bills for the services provided by a resident in training. The rules stipulate that the APN services must be provided under protocols and in accordance with any rules by the Texas Medical Board (TMB). Clearly this law applies to any NP working in a facility-based practice or in a physician's primary practice site where a physician is available at least 50% of the time. However, in researching these rules, I found no prohibition against using this same billing practice in a site where the physician is present a smaller percentage of the time. If a physician delegates prescriptive privileges to a NP in a medically underserved area, those services may be billed under that physician's name if he or she meets certain minimum conditions specified in the TMB rules. The physician must:
- review and sign the practice guidelines or protocols annually;
- be on site at least once every 10 business days;
- review at least 10% of the charts while on site.
- maintain a record of the physician's quality assurance activities and names of patients seen while at the APN's practice site.
Although I certainly recommend that nurse practitioners bill under their own names whenever financially feasible, NPs should be aware that rules for billing Texas Medicaid under a physician's name are much more liberal than when billing Medicare. For small practices that see a large proportion of Medicaid clients, the difference between 100% reimbursement and 92% can mean the difference between financial life and death. It is also important in many medical school settings that physicians know they can bill for an APN's services without having to conform to the same supervision standards that apply to billing for services provided by residents.
Whether billing under Medicare, Medicaid or private insurance, one word of caution is warranted. The NP and physician must be sure no double billing occurs for the same service. Obviously the physician and NP cannot bill for the same service. However, sometimes double-billing is far less obvious. For instance, neither the physician or NP can bill Medicaid for a service provided in a school-based clinic if the school district bills for that service under the School Health and Related Services (SHARS) program. Regardless of the circumstances, be sure that only one entity bills for any service. |
