"Incident-To" Billing NOT Allowed by BCBSMT

Jul. 26, 2017

One of the most common complaints received on the Blue Cross and Blue Shield of Montana (BCBSMT) fraud hotline is from patients complaining that services received from a non-physician provider (physician assistant, nurse practitioner) have been billed under the name of a physician in the clinic. The BCBSMT Special Investigations Department has identified the practice of submitting claims under the wrong provider name and National Provider Identifier (NPI) as the number one problem addressed by the unit. When identified, however, many providers justify the billing as being incident-to services.

The Centers for Medicare and Medicaid (CMS) defines incident-to services as those that are "furnished incident to physician professional services in the physician's office (whether located within a different office suite or within an organization) or in the patient's home." Incident-to billing is an allowable practice when billing Medicare, as long as you meet the specific requirements set forth by Medicare.

BCBSMT, however, does not recognize incident-to billing, but requires that claims be billed under the name of the provider who actually rendered the service. Your NPI number is the key to prompt payment of claims. Always include this number when submitting claims for BCBSMT members; otherwise, the claims will be returned to you. Providers must submit claims for services under the NPI number assigned to them; submitting claims for payment under another provider's NPI may be considered fraud as defined under Montana Code Annotated 33-1-1202(1). A provider may not let another provider use their NPI number to submit claims to BCBSMT except as described in the Locum Tenens Policy or Provider-in-Training Policy. Copies of these policies are available at www.bcbsmt.com. (Login and click on Providers and then Provider Policies).

It is important to submit claims for services provided by a non-physician practitioner under their NPI, since they are subject to a different fee schedule than a physician. This holds true whether the non-physician provider is supervised by a physician or not.

To submit claims correctly for non-physician providers:

  1. Make sure all providers in your office have obtained an NPI through the National Plan & Provider Enumeration System, and only use their number for services rendered by the treating provider.
  2. Always submit claims using the name and NPI of the provider who rendered the service.
  3. Do not use a supervising physician name to submit claims for services rendered by a non-physician provider, even though those services may be approved by the supervising physician. Submission of non-physician claims under a physician name results in increased reimbursement and may be reported to authorities.

Reimbursement of overpayments will be pursued when identified. If your office has been billing non-physician services incorrectly, contact the SIU, and we will work with you to ensure future claim submissions are correct and that any claims processed in error are corrected. More information about submitting claims can be found in the BCBSMT Provider Manual at bcbsmt.com.