“TMA Practice Consulting is an incredibly helpful management resource for physicians who work with or plan to work with NPPs.”


sulting understands the many levels of complexity to supervising NPPs,” said Mr. Rivera.


NPP billing, credentialing Proper credentialing is key to the finan- cial success of a practice that employs NPPs.


The American Medical Association re- ports the number of U.S. physicians in- creased 29 percent from 1996 (737,764) to 2008 (954,224). The Health Resourc- es and Services Administration says the number of NPs increased 123 percent from 70,993 to 158,348 during that same period. According to the American Academy of Physician Assistants, the number of PAs grew 153 percent from 29,161 in 1996 to 73,893 in 2008. NPP utilization among physicians


reflects their growing numbers. “Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants in Physician Offices,” an August data brief published by the Centers for Disease Control and Prevention (CDC), indicates 49 percent of office-based physicians use PAs, NPs, and/or certified nurse midwives (CNMs). The brief highlights the percentage of physicians using NPs, CNMs, or PAs by specialty, age, revenue source, and prac- tice size. NPPs’ increasing demand and use among physicians can be attributed to the economy, improved training, and technology, says Julian Rivera, JD, an attorney in the Austin office of Brown McCarroll, LLP. Mr. Rivera represents physicians in legal matters related to NPP utilization. “Patients and payers are demanding lower costs and higher efficiency. Tech-


28 TEXAS MEDICINE March 2012


nology is facilitating communication be- tween NPPs and supervising physicians. Electronic health records, electronic pre- scribing, and electronic communication tools allow physicians who supervise NPPs to examine data in real time, in- tegrating care and ensuring everyone is working from the same record,” Mr. Ri- vera said. According to the Medical Group Man- agement Association’s (MGMA’s) 2011 Physician Compensation and Produc- tion Survey (based on 2010 data), the median salary for a nurse practitioner was $87,649, and median collections were $174,444. A PA’s median salary was $90,001, with median collections totaling $167,336. The same survey in 2009 found that


for every dollar of charges a PA gener- ates for a medical practice, the employer pays an average of 30 cents to employ the PA, not including overhead costs. Texas Medical Association Practice Consulting offers a variety of services that can help practices hire NPPs and make sure they follow coding and docu- mentation and billing and collections re- quirements. (See “TMA’s NPP Resources,” opposite page.)


“TMA Practice Consulting is an in-


credibly helpful management resource for physicians who work with or plan to work with NPPs. TMA Practice Con-


Practices that use NPPs have two op- tions for getting paid: billing under the NPP’s provider number or billing the services “incident to” under a supervis- ing physician’s provider number. In oth- er words, when billing “incident to,” an NPP’s services may be billed as if a phy- sician provided the services. “Incident to” refers to services and supplies commonly furnished in a physician’s office that are related to the physician’s services. Billing “incident to” requires supervis- ing physicians to adhere to stringent re- quirements. For example, the physician must be in the office suite and immedi- ately available to assist during the NPP’s treatment.


Additionally, NPPs can’t bill “incident to” for new Medicare patients or Medi- care patients who present with a new medical problem. NPPs who bill “inci- dent to” don’t have to be individually enrolled in health plans. “Incident to” is a Medicare billing policy and therefore may not be clearly addressed by other payers. In fact, Mr. Rivera says some commercial insurance plans adopt the Medicare standard for “incident to” billing, and some don’t have a policy on “incident to” billing at all. If an insurer lacks an “incident to” policy, Mr. Rivera advises physicians to consult an attorney. “Legal requirements for physicians who work with NPPs are often changing, and in some cases it’s an opaque area of a physician’s business. It’s wise for a practice to consult with trusted counsel at the business and legal level to ensure patient care is being delivered with high quality, good efficiency, and complete compliance,” he said.


Medicaid allows physicians to bill for


the services of other practitioners in spe- cific circumstances. For example, Medic- aid says that for a PA, “[e]nrollment as an individual provider is optional. PAs currently treating clients and billing


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