UnitedHealthcare (UHC) recently implemented changes to its Advanced Practice Health Care Provider (APHC) policy that requires nurse practitioners (NPs), physician assistants (PAs) and clinical nurse specialists to bill under their own NPIs, virtually eliminating the ability to bill for services as “incident-to” the physician services and limiting reimbursement for such services to 85% of the physician fee schedule. Under the new policy, UHC will only reimburse services billed as “incident-to” a physician’s service if the APHC provider is ineligible for their own NPI number and the “incident-to” guidelines are met. The policy change for UHC commercial products was effective March 1, 2021, and for exchange products was effective on May 1, 2021.

The California Medical Association (CMA), in its evaluation of this updated UHC policy, is concerned that the UHC policy is inconsistent with the Centers for Medicare and Medicaid policy (CMS) on  billing “incident-to” services.  Providers who bill “incident-to” services following the CMS guidelines, including under Medicare, are typically paid at 100% of the physician fee schedule.

In discussions with UHC regarding the potential financial impact of this new policy upon physician practices, CMA learned that UHC is now contracting directly with advanced practitioners including nurse practitioners, physician assistants and clinical nurse specialists. While advance practitioners were always required to be fully credentialed with UHC, the payor reports that over the last two years it has begun adding advanced practitioners to physician or group agreements.  CMA is further inquiring with UHC as to whether there are any exceptions to the policy based on the contract.  An advanced practitioner contracted independently can join the UHC network by submitting a Request for Participation on  the UnitedHealthcare website at uhcprovider.com/join. 

A request to add an advanced practitioner to an existing group agreement can be submitted via the UHC website at uhcprovider.com >Demographic Changes or send the request via email to hpdemo@uhc.com.

CMA is working to address the unique challenges experienced by practices impacted by this new policy. If your practice has experienced challenges, CMA wants to hear from you.  

Contact: Mark Lane, Director of CMA’s Center for Economic Services, at (888) 401-5911 or mlane@cmadocs.org.