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March 29, 2021

Journal of Health and Life Sciences Law

Billing for Advanced Practitioner Professionals and Traps for the Unwary

  • March 29, 2021
  • Mackenzie Wallace , Thompson Coburn LLP
  • Emily Miller , Andrews Myers PC
  • Brett Rector , Thompson & Knight LLP
  • Joseph Aguilar , HMS Valuation Partners

In an already complex billing landscape, billing for advanced practitioner professionals (APPs) may present one of the most complex billing systems. As a result, APP billing is ripe for potential liability. This article outlines and simplifies the alternatives for billing APPs and highlights traps for the unwary.

Proper billing for APPs begins with an understanding of who qualifies as an APP, what services provided by APPs are reimbursable, and the types of APP billing. The three types of APP billing­—(1) direct billing, (2) “incident-to” billing, and (3) split or shared billing—each require under the Medicare Part B reimbursement guidelines that the services be rendered under specific conditions, which are discussed in detail herein.

Moreover, APP billing can impact fair market value in the provision of services under various financial arrangements. Significant traps for the unwary exist regarding fair market value analysis, including accounting for APPs used as “extenders” for physicians, compensating physicians for APP supervision, employing APPs to assist contractors under separate professional services agreements (PSAs), and using APPs concurrently to assist physicians in providing ER on-call services.

These complex aspects of billing and payment of APPs must be carefully and thoroughly analyzed through the lens of how private and government payers reimburse for services rendered by APPs

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