UnitedHealthcare (UHC) has made changes to its recently updated Advanced Practice Health Care Provider (APHC) policy that required 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. In the UnitedHealthcare Commercial Reimbursement Policy Update Bulletin for August 2021, UHC indicates that it has updated the APHC policy, effective August 1, 2021, to allow services by APHC providers to be billed as “incident-to” a physician’s service if the “incident-to” guidelines were met. The original policy change for UHC commercial products was effective March 1, 2021, and for exchange products was effective on May 1, 2021.

In addition to the changes incorporated into the APHC policy, UHC has also now created a separate Services Incident-to a Supervising Health Care Provider Policy, Professional policy, which outlines the requirements and criteria for reporting the service provided as “incident-to” a supervising health care provider by an APHC provider or nonphysician provider including billing under the supervising physician’s NPI number and required usage of the SA modifier.

In evaluating the original APHC policy, the California Medical Association (CMA) expressed concern that it was inconsistent with the Centers for Medicare and Medicaid policy (CMS) on  billing “incident-to” services, but UHC has confirmed that the recent changes now align fully with CMS policy. Providers who bill “incident-to” services following the CMS guidelines, including under Medicare, are typically paid at 100% of the physician fee schedule.

NPs, PAs and clinical nurse specialists who were required to bill under their own NPIs and not “incident-to” the physician services prior to August 1, 2021, limiting reimbursement of their services to 85% of the physician fee schedule, will need to resubmit a corrected claim to be eligible to be paid at the physician rate. As per the UHC Services Incident-to a Supervising Health Care Provider Policy, Professional, providers that meet the “Incident-to” criteria should be reported under the supervising physician’s NPI number and the SA modifier should be appended.

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