March 04, 2022

Unintended Consequence  

By Jill Young, CPC, CEDC, CIMC

As a member of the WPS Medicare Provider Outreach and Education and Education Advisory Group (POE AG) I was made aware of some disturbing information during a recent meeting.  The concern has been a known issue in the past.  However, now with increased numbers of claims are being submitted by Nurse Practitioners or Physician Assistants, there is now a more widespread problem of rejections for these types of claims with no payments being made.  The problem occurs in large groups or hospital systems where there are multiple specialties under the same tax ID, and Nurse Practitioners and Physician Assistants that work for those specialties are involved in the care of the patients (predominantly in the hospital).

Previously when multiple services by multiple physicians of differing specialties were performed on the same date, the claims submitted were paid by Medicare.  They did not show as concurrent care because the specialty denotation of each physician Medicare had on file showed that the services were performed by differing specialties.   Looking at that same scenario where perhaps two of the specialties had billings under their Nurse Practitioners (NP) is now a problem because the specialty denotation for the NP is simply Nurse Practitioner (50).  There is no medical specialty associated with their number.  The first claim submitted in this example is paid, but the second one is not.  Medicare sees the second claim by the same provider type is concurrent care and rejects that claim.  To Medicare, providers of the same specialty under the same Tax ID are seen as one provider.  The same is true when looking at this  scenario for Physician Assistants (PA) whose specialty denotation is Physician Assistant (97).

In a large system that utilizes Non-Physician Practitioners (NPP) of this type, rejections for a particular patient’s claims submitted for a date of service can be significant, depending on the number of NP or PA provider specialties that are submitting claims on a particular date.

WPS Medicare has indicated that they cannot change policy, only CMS/Medicare can.  On the POE AG call several members indicated they had received multiple rejections on patients for dates of service when one of these two provider types (NPs and PAs) submitted multiple claims.  Again, this is one of these provider types submitting claims on the same patient on the same date of service (i.e. several NP’s of differing specialties) 

This type of rejection for overlapping services by Nurse Practitioners or Physician Assistants can happen anytime in a large system including office New Patients (when an NP or PA has seen the patient at another location and the patient goes to a different specialty practice in the system and is seen by the same provider type (NP or PA).  If the NP from the first practice bills a new patient visit when the NP from the second practice in the same system under the same tax ID bills a new patient visit, the Medicare claim will reject.  Again, this is because there is no specialty associated with the NP’s specialty number.  The same is true if both providers were PA’s as well.

Unfortunately, this is not to offer any solution, but rather bring to your attention a problem that already existed but is now exacerbated by CMS/Medicare’s redefinition of their Split or Shared Policy.  It is, perhaps an unintended consequence of the policy change that should be addressed.