“One of these things is not like the other”
Much has been written about the current high demand for mental health services and (supposed) clinician shortages.* Some (not all) private insurers have begun reimbursing supervisory billing, which was unheard-of outside Medicaid even just a few years ago. Medicaid generally has always reimbursed for supervisees, probably because of traditionally low reimbursement rates.
*(If you ask me, the “shortage” isn’t that there aren’t enough clinicians. It’s that there aren’t enough clinicians willing to work for reimbursement rates that haven’t kept pace with inflation, the cost of doing business, and the cost of training. To say nothing of the constant administrative hassles I regularly write about.)
You’ll notice I didn’t mention Medicare: what about Medicare? As always, Medicare is confusing!
Medicare does NOT reimburse services provided by provisionally-licensed clinicians!
But….!
You’ve probably heard that Medicare has this thing called “incident-to billing” (true).
And that it’s ok for you to bill Medicare for supervisees under “incident-to billing” rules (false).
But what about “incident-to” billing?
The key is that “incident-to” and supervisory billing aren’t the same thing. Not at all. But many people, including some insurance companies, confuse or conflate supervisory billing and “incident-to.”
How are incident-to billing and supervisory billing different?
Every state requires a certain number of hours of supervised clinical practice before a therapist can obtain independent licensure. Supervisory billing is just what it sounds like: a licensed clinician is billing under their group’s NPI number for services provided by a therapist who isn’t yet independently licensed.
However, with supervisory billing, there is no clinical requirement for client’s care that must be met. The payer either reimburses for treatment provided by supervisees, or it doesn’t.
“Incident-to” requires that clinical (and other) criteria be met.
Incident to services and supplies are those provided as
an integral, although incidental, part of the physician’s or
nonphysician practioner’s personal professional services during
diagnosis and treatment.
For example, a patient is diagnosed by an MD with diabetes, is prescribed medication which requires careful monitoring. The MD also sets up a plan of regular blood sugar evaluations by a nurse practitioner who is part of the physician’s practice. This NP’s services are billed “incident-to” the MD’s services. Meaning that the MD’s billing includes the nurse’s services.
How this differs from supervisory billing:
- The physician personally evaluates the patient first, and develops the plan of care.
- The NP could bill under their own license/NPI, if they were treating the patient independently, and if their treatment plan was their own.
- The referral to the NP is a critical component of the MD’s treatment plan for management of the patient’s diabetes.
- The physician continues to monitor and directly treat the patient, in addition to overseeing the nurse’s monitoring plan/progress.
- The physician is required to be available for immediate supervision & intervention, either in person or via telehealth.
See the difference? “Incident-to” is meant to show coordinated care, or services associated with the “main” billable service, billed together as a comprehensive plan of care.
In mental health, the clinical requirements for “incident-to” aren’t commonly met in office-based psychotherapy practices.
Why?
Because in psychotherapy the associate (supervised) therapist IS the treating clinician. The supervisor is acting as a case consultant. Supervisors don’t evaluate the client first, and typically never even see the client except in cases of illness or emergency. Therefore, supervisory billing does not meet “incident-to” guidelines.
Be honest: are you satisfying the clinical conditions for “incident-t0” in office or telehealth psychotherapy settings when services are provided by provisionally-licensed therapists?
(you don’t have to tell me…)
But, if you’re billing Medicare for supervisees, and calling it incident-to, then STOP. RIGHT. NOW.
If the above isn’t enough to convince you, then maybe this will: master-level therapists aren’t even allowed to bill “incident-to” services under Medicare. Yup, that’s right. Only physicians, physician assistants, psychologists, and clinical nurse specialists/nurse practitioners are allowed to bill Medicare “incident-to.”
And, furthermore, provisionally-licensed clinicians can’t furnish services to Medicare beneficiaries – even using “incident-to.” Only fully-licensed clinicians can. (Which begs the question as to why you would need “incident-to,” in a private-practice setting.)
Want that in writing (although stated in an extremely confusing manner) ? Click here.
Would you like to feel confident with Supervisory Billing?
Supervisory Billing and Private/Commercial Insurance
If a private insurance payer has publicly stated in writing (usually in their provider manual), that they will reimburse for supervisees … feel free.
But this being insurance – there’s a catch. Or several.
One is that commercial insurance payers commonly use the term “Incident-To” and in the same sentence, or paragraph, imply that mental health clinicians requiring supervision qualify.
I suspect that payers who compose these manuals don’t differentiate between medical services, where incident-to is standard, and mental health, where it is not (at least in the private practice office/telehealth setting).
The payer’s documentation needs to be read thoroughly and carefully. If they decide to claw back, appeals based on you not understanding will be useless.
Another catch: insurers who may cover supervisory billing, don’t necessarily cover it for ALL plans. Remember I said that Medicare doesn’t cover supervisory billing? Well, that extends to Medicare “Advantage” plans, operated by private payers. So while Aetna commercial plans will allow supervisory billing, Aetna Medicare “Advantage” will not.
Then there are employer-designed plans, known as “self-insured.” These might be administered by a subsidiary of a payer who allows supervisory billing. To continue with the Aetna example, this could be a Meritain plan. But in the event of an employer-designed plan, whatever is specified by the employer is what counts – even if it goes contrary to Aetna’s published policy.
Finally, the actual method of submitting a supervisory billing claim can be quite different from payer to payer. It’s 2020 and telehealth all over again – nobody can come to consensus about how supervisory should be billed! (They aren’t even TRYING to…!)
Some payers will use the official Medicare “incident-to” method; others won’t.
I thought you said “Incident-To” and Supervisory aren’t the same thing?
Clinically, they aren’t.
But the way to set up claim forms is one of the main reasons “incident-to” and supervisory billing get conflated.
Part of your Supervisory Billing challenge, if you choose to accept it, is to determine if the payer will accept the standard billing protocol described in the video. Are there any modifiers required? Some payers will require -SA, others will require -U5, and still others don’t require modifiers.
But some payers don’t want a supervisory claim filed according to standard CMS/National Uniform Claim Committee guidelines, where the supervisee is listed in 24J as the rendering provider and Box 17 is used to denote the supervisor. Instead, they want the supervisor to bill “as if” they themselves performed the service. The supervisee is nowhere on the claim, and just from the claim, you can’t tell the service was rendered by an associate.
There are hidden traps to this method!
The numbers problem. Billing without reference to the supervisee as the rendering provider inflates the number of sessions billed under the supervisor’s Type 1 NPI. Thereby putting the supervisor at extremely high risk of extensive audits.
Example: the supervisor sees 3 clients per day with the same insurance payer. The supervisor has 3 associates, and each of them sees 3 clients per day with the same insurance payer. That’s 12 sessions per day billed to the same insurer under the supervisor’s NPI.
This will trigger an audit under “Medically Unlikely Edits” – because 12 visits in one day is well beyond what any one clinician can handle.
The documentation problem. I have yet to see any one payer spell out exactly what they consider acceptable documentation of “supervision.” Licensing boards only want supervisors to attest to the number of hours performed, but I suspect insurance companies are a little harder to please.
Because they don’t specify what level of documentation needs to be completed, this opens a gateway for clawbacks when auditors decide that documentation is “insufficient.”
Finally, there are the uncomfortable client situations that can (and do) arise:
1. What happens when an associate forms a therapeutic relationship with a client, and the client’s insurance changes to a plan that doesn’t allow supervisory billing?
Difficult choices: self-pay at a reduced rate, referral to the supervisor or another licensed clinician. Possibly harmful to the client, and stressful for the new therapist, having to navigate ethical dilemmas even before their career has truly begun.
2. What if it’s a situation with primary vs secondary insurance? One plan might allow associates while the other doesn’t – and coordination of benefits is frequently not clear or updated.
Same as above – plus more confusion. Clawbacks are likely. And care is disrupted.
3. Mental health carve-outs. The main medical plan may allow supervisory, but the mental health vendor doesn’t. Or a third-party administrator (such as the Aetna/Meritain example mentioned above).
4. Plain old difficulty in determining coverage! It’s hard enough sometimes just to know what the client is supposed to pay…let alone if supervisory billing is covered!
5. When your supervisee gets their license, now they have to go through credentialing – which can take months. And even if they’re staying with your group, you can’t bill for them anymore. So now what? Out of network? Single-case agreement?
If after all this you’re still committed to the training of supervisees – good for you! I have your back and am available for individual/group consultation as issues arise.
Susan has been featured in The New Yorker and on Therapists Unchained and other podcasts.
