Aetna Reduces Reimbursement for Mid-Level Providers

August 02, 2010

In the March and June 2010 edition of OfficeLink Update, Aetna Insurance Company’s newsletter for network providers, Aetna announced that it will be revising their payment policy for mid-level providers to conform with Medicare’s “incident to” policy, effective June 1, 2010. Under the new policy, nurse practitioners, physician assistants and clinical nurse specialists who had been paid the full physician-fee-schedule amount for all services will now be paid at 85 percent of the fee schedule for new patient visits and consultations and any other services that do not meet the “incident to” guidelines. The Medical Society of North Carolina was successful in delaying the change until the current provider contracts expired.

The “incident to” policy allows a physician to bill for a service performed in the office by an employee of the practice if the billing physician is present in the office suite when the service is performed and the service is part of a course of treatment prescribed by a physician in the group. As such, only established patient visits in the office performed by an employee can be billed under the physician. New patient visits (and formerly, consultations) must be billed under the provider number of the person who provided the service. In addition, services performed in the office cannot be “shared.” Even if the physician sees the patient during the visit, the service must be billed under the provider that performed the essential part of the service and documented the service.

Medicare does allow for a “shared” visit in the hospital. If the mid-level provider who is an employee of the group sees the patient and documents the service, and the physician sees the patient on the same day, the physician can bill for the combination of both services. If the physician does not see the patient on the same day, the service must be billed under the mid-level’s provider number. Consultations, though no longer billable to Medicare, could not be shared.

Given Aetna’s move to Medicare’s policy, what would be the most cost-effective services that can be provided by a mid-level provider?

  • Established patient visits for patients seen initially by a physician and who have a chronic condition (GERD, hepatitis, IBD) that require periodic visits. A physician in the group must be present in the office suite when the service is provided, but the physician does not have to see the patient nor review the note. The service is billed under the physician who is present in the suite when the service is provided, not the patient’s regular physician.
  • New patient visits in the office when a patient requires an urgent visit and no physician is available to see the patient.
  • All visits in the hospital. If the physician sees the patient on the same day, the combined service can be billed under the physician. If the physician does not see the patient on the same day, the service must be billed under the mid-level’s provider number.

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