Billing and Compliance Challenges for Advanced Practice Professionals

Thompson Coburn partner Milada Goturi was a co-presenter at a program hosted by the American Health Law Association, which was titled “Navigating Billing and Compliance Issues for Advance Practice Professionals.” The program addressed the important regulatory aspects since healthcare organizations are becoming more dependent on nurse practitioners and physician assistants, also referred to as Advanced Practice Professionals (APPs).

The increasing volumes of patients, ongoing shortages of physicians, the increasing cost of operations, and the narrowing reimbursement are the factors that are stimulating the increased use of APPs. Although APPs are generally known to positively impact access to care, patient and provider satisfaction, enhancing efficiency, and cost savings. But the broadening of their responsibilities has also escalated the risks of billing and compliance in healthcare providers. These are:

1. Medicare Billing Requirements

One of the main aspects of the discussion was meeting Medicare billing requirements. Medicare allows a number of billing methodologies of APP services, such as direct billing, incident-to billing, and split (or shared) billing. Every approach has its own rules and restrictions. For example, the incident-to billing should never be applicable in a hospital setting, and split/shared billing cannot be applied in a physician's office setting. Providers are vulnerable to audits and enforcement of these billing models due to their misuse. Private payors may or may not follow Medicare billing requirements.

2. Compliance With State Professional Licensure Law

Another significant compliance area was pointed out to be state professional licensure laws. The jurisdiction requirements are very different, as some states permit APPs to practice fully and others require a certain number of physicians to oversee them. The practices should comply with state-specific regulations, such as limits on the ratio between physicians and APPs, the documentation of the necessary chart or medication review, and the need to have on-site physicians.

3. Compliance With Hospital Licensing Requirements

Lastly, the program also placed much importance on aligning the use of APP with the hospital licensing regulations, Medicare Conditions of Participation, and accreditation requirements. All the frameworks can have extra requirements that influence the form of the APP services structure and implementation.