Understanding Medicare Reimbursement Essay.

Posted: December 27th, 2022

Understanding Medicare Reimbursement Essay.


There are several subtopics under the rubric of reimbursement to be covered this week:

Understanding Medicare reimbursement and “incident to” is paramount to an APN’s career (NOTE: Strictly speaking the term incident to is a Medicare expression. While some commercial insurance companies and some states’ Medicaid plans might mimic this practice, they do not necessarily require all of the associated Medicare criteria.)Understanding Medicare Reimbursement Essay.


The first question you must address is: Should the organization use “incident to” billing? Why or why not? In other words, you first need to explain what Medicare requires for an organization to legitimately bill incident to. Next you need to explain whether incident to billing makes financial sense for your organization in light of Medicare criteria. Be sure to read the Buppert and Nagelkerk assignments carefully before you compose an answer. Finally, also based on those reading assignments, briefly share some thoughts about billing Medicaid and commercial insurance companies for APN services.Understanding Medicare Reimbursement Essay.


The next topic concerns how your organization can avoid Medicare fraud and abuse when using APNs; specifically regarding the Stark Acts: What do you and the APNs in your organization have to know about this?

The organization should not use “incident to” billing. “Incident to” billing involves midlevel providers offering services that are incidental to physicians’ supervision and input. To be more precise, it entails midlevel providers performing work that is billed under the supervising physician’s NPI number. This results in 100% reimbursement instead of 85% reimbursement if the billing had been done under the midlevel provider’s NPI number (Rapsilber, 2019). Although this approach increases reimbursement by 15%, it presents some concerns. Firstly, new problems cannot be presented under “incident to” billing, and must be billed under the midlevel provider’s NPI number. This can be confusing for the billing staff. Secondly, it has a direct supervision requirement that is difficult to fulfil. Failing to meet this condition would require that the NPI numbers be switched between the physician (when present) and the midlevel provider (when the physician is unavailable). The issue could be complicated if the billing is done by the biller after the fact and it is unknown for which care aspects the provider was present. Thirdly, it creates confusion among patients whose records will indicate that they received care from physician X and yet they received care from a non-physician practitioner (NPP). This confusion could create the perception that the billing was friendly, especially if the patient does not understand the concept of “incident to” billing. Overall, it is clear that “incident to” billing is not suitable for the organization since it has many administrative burdens and inflexible requirements. The 15% increase in reimbursement is not worth the associated hassle, risk of errors and penalties in case errors occur and are identified during audit(Kopanos, 2013; Shay, 2015).Understanding Medicare Reimbursement Essay.

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