Texas Blues Reverses Policy to Discontinue Incident-To Billing

 

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In response to Texas Medical Association advocacy, Blue Cross and Blue Shield of Texas (BCBSTX) reversed a new policy under which the insurer would have discontinued paying the full payment rate for “incident-to” services performed by nonphysician practitioners (NPPs). 

BCBSTX will pay 85% regardless of whether the service is billed incident to or directly.

TMA’s concerns stemmed from a policy statement BCBSTX issued in January 2021 indicating it would no longer pay for incident-to claims “with the SA modifier,” and instead encouraging board-certified physician assistants (PAs) and nurse practitioners to contract and get credentialed with the health plan so they could bill for their services under their own National Provider Identifier (NPI) number.   

TMA had raised concerns with BCBSTX that the policy change effectively would end the long-standing practice of incident-to billing and result in a 15% payment cut to physician practices. Payments for claims billed using an NPP’s NPI number are typically 85% of the physician’s rate. 

In a policy update issued in May 2021, BCBSTX said the change “has not been implemented and there are currently no plans for future implementation of this edit.”  

The insurer also explained that the “SA modifier” for incident-to billing should be used in the following ways: 

  • By the supervising physician, when he or she is billing for services rendered by a PA, advanced practice nurse (APN), certified registered nurse first assistant, or licensed surgical assistant; and 

  • On claims submissions by PAs or APNs when billing under their own NPI number for assisting with any other nonsurgical procedures. 

TMA also sent a letter to UnitedHealthcare (UHC) with concerns over a similar policy revision. For now, the UHC policy stands.  

For questions, contact TMA’s Reimbursement Services at (512) 370-1414. 


 

Last Updated On

May 25, 2022

Originally Published On

May 13, 2021