Texas Blues Reverses Policy to Discontinue Incident-To Billing, Averting Pay Cut
By Amy Lynn Sorrel



In response to Texas Medical Association advocacy, Blue Cross and Blue Shield of Texas (BCBSTX) has 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). 

TMA’s concerns stemmed from a Jan. 19 policy statement by BCBSTX 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 May 12 policy update, 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 recently sent a letter to UnitedHealthcare (UHC) with concerns over a similar policy revision and awaits a response. For now, the UHC policy stands.  

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


Last Updated On

May 14, 2021

Originally Published On

May 13, 2021

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