Categories: Health Law,

Medical practices can now send bills to Medicare for pharmacist services on an “incident to” basis, healthcare attorneys in Fort Lauderdale report. As part of the medical home model touted by the Affordable Care Act (ACA), this new billing practice will make patient-centered medical facilities more financially sustainable. 

The ACA promotes the medical home model, which keeps healthcare in a teamwork-type setting. The medical home model uses a widespread and diverse group of professionals throughout various fields of healthcare, usually headed by a physician, all of whom work together to deliver quality care for patients. To include pharmacists in the “incident to” billing plans will help centralize healthcare, according to this model. 

“Incident to” services are defined as services or supplies that have been provided as an integral but incidental part of the physician’s professional services, during the course of a diagnosis or a treatment plan. The physician, pharmacist, or other professional does not have to be the person who provides the service, but must be an employee of the primary care physician. Additionally, any services that are provided under the “incident to” billing provision must be precluded by an initial visit to the doctor or primary care physician, who must order the course of treatment or diagnostic tests that require an outside service.  

Physicians usually use the “incident to” provision to receive reimbursement for services rendered by nurse practitioners and physical therapists who may have helped a particular treatment plan for a patient. For this reimbursement, Medicare pays 100 percent of what it would pay the doctor, as long as the requirements for “incident to” billing are met, such as direct supervision by the primary care physician, and employee status. The outside party can be employed outright, or be hired as an independent contractor or leased employee. 

A pharmacist directly related to a primary care physician seems to fall under this category as well, but has previously not been included in the “incident to” billing provision for Medicare. In January 2014, just a few months after the ACA was made law, the American Academy of Family Physicians (AAFP) asked Marilyn Tavenner, the administrator of the Centers for Medicare and Medicaid Services (CMS) to consider expanding the “incident to” billing policy to pharmacists who work with physicians. The AAFP argued that a face-to-face meeting with the pharmacist had “all the trappings” of a doctor’s office visit, and Tavenner agreed. 

Assuming all the necessary requirements are met, physicians can now bill Medicare for a pharmacist’s work using their own provider numbers. Tavenner did add two conditions to this new plan: first, that the “incident to” billing can only be used as long as the auxiliary service provider is included in the scope of their state licenses, and second, that medication management services, which are not covered in Medicare’s Part B program for physician reimbursement, will remain outside of “incident to” billing. 

The new mandate from the federal government will make it easier for patients who use Medicare to pay for procedures that do not fall into the direct category of preventive care or routine doctor’s visits, healthcare attorneys in Fort Lauderdale say. At Lubell Rosen, our attorneys represent medical professionals in Florida, Georgia, New Jersey and New York with a variety of legal services and consultations.