Incident-To Billing

Health Law Talk presented by Chehardy Sherman Williams

+ Full Transcript

Rory Bellina (00:13):
Hello everyone and welcome to Health Law Talk presented by Chehardy Sherman Williams. Before we get started, please be sure to subscribe to our podcast and follow us on Facebook, Twitter, LinkedIn, and YouTube – links in the description below. We hope you enjoy this episode.

Conrad Meyer (00:36):
All right. Good morning everyone. Conrad Meyer here for another edition of Health Law Talk here at Chehardy Sherman Williams with Rory Bellina. And Rory, say hello. Good morning. Good

Rory Bellina (00:47):

Conrad Meyer (00:48):
Everyone. And today, everyone, we have a a special guest with us today. Keith Hustak. he is the Vice President of Advanced Provider Practice and Vice President of Operations for Spectrum Health. And he’s on the line with us today. Keith. Keith, how you there? You there?

Keith Hustak (01:05):
Yes. Good morning. Thanks for having me.

Conrad Meyer (01:07):
Great, great. Today we’re gonna talk about something that that all of us have dealt with, and especially Keith with respect to advanced provider practice, APRNs physician assistance, and that deals with incidents who billing requirements. And a lot of you are gonna scratch your head, say, What, what incident to what is that? And it’s, it’s actually a very, very important topic because incident two is, is if done properly, and if in compliance can help practices and large groups capture additional revenue from Medicare. If done wrong, you have a real problem with potentially opening up your practice, your group to a false claims act as well as civil monetary penalties. So a lot of times people scratch their head and say, Well, I don’t even know what that means. What does incident to? So today we we with Keith on the phone and, and Rory and I we’re gonna explore the world of incident two. So with that being said, we’re gonna jump right in. today. When, when you look at incident to Keith, what, what’s your understanding of a, of, of why incident to would be important to a large group like Spectrum?

Keith Hustak (02:24):
Yeah. Incident to is, is it’s critical to understand the details because if you don’t get the details right you know, you could be then accused of, of false billing practices. And you know, I think when I speak across the country, you know, providers, physicians, APTs, PAs, APRNs, I think that the, the traditional, and, and I don’t have any data on this but I think the traditional provider really doesn’t understand the details of incident two very well. And that puts us all at risk.

Conrad Meyer (02:57):
So, so let’s,

Keith Hustak (02:57):
Let’s, that’s, that’s, that’s why it’s

Conrad Meyer (02:59):
Important. So let’s, let’s jump back. What is it? I mean, like, that’s like the, it’s sort of like the, the, the, the, the thousand pound elephant in the room. What is it? Yep. So go ahead, Keith. What’s your under, what is incident? So how would you, how would you, in a layman’s terms, how would you describe incident to?

Keith Hustak (03:20):
Yeah, so here’s, here’s how I describe incident two. And, and we give a cast for the moment lecture at Spectrum, really to teach providers this. But incident two, the way I teach it as this incident two starts at, at a second visit, a subsequent visit after a physician has seen a CNA patient and has established a plan of care for that patient mm-hmm. and I’ll, I’ll give an example of this. So, so the classic example is, you know, a physician sees a, a patient who has hypertension mm-hmm. . And that physician says, Okay, we’re gonna start you on this blood pressure, me blood pressure medication. I’m gonna have you follow up with your you know, with my A P p in six weeks, and we’re gonna see how that blood pressure medication is doing and how you’re doing. incident two then starts the possibility of instance two starts at that subsequent visit.

So at that subsequent visit, you know, the PAs, the the patient in notices what the physician’s plan of care was, if the, the PA or the APRN is seeing that patient and says, Okay I see the plan of care here, patient’s doing well on this, on this blood pro blood pressure medication and, and follows that plan of care that was established previously by the physician and doesn’t change the plan of care, doesn’t see any new diagnoses, and here’s kind of the, you can’t make this stuff up. Right. The, the key to it is, is that a, a physician who is working in that same group has to be in the office at that time. If all that criteria is meant, then they can build incident two. And what that essentially means is incident to the physician and can get a hundred percent of the service almost as if you’re doing like, like under the physician essentially.

And that’s what incident two is, I always teach a incident. Two really is a, an outpatient follow-up visit term. It’s also a CMS term meaning that a lot of like commercial payers, in fact they don’t really deal with incident to. Like, like here in our market in Michigan some of our payers don’t credential apps, and because they don’t credential apps, we don’t really have to even have to deal with it on the commercial side. So again, outpatient CMS term follow up visit, pH a a physician, not the physician who saw the patient by the way, but a physician needs to be in the office at that subsequent visit. If all that criteria’s met and you don’t change the plan of care, you can bill incident to. It’s that simple.

Conrad Meyer (05:51):
So, So if, and so, and, and, and just just so everyone understands Keith, you, you manage just a few aps, right? 700, 700, 700,

Keith Hustak (06:01):
We have 700 aps in our system. That is, that is, we have

Conrad Meyer (06:04):
A lot, lot, That’s a lot of aps. Yeah. well, well, and, and you’re right. So, so the different, the difference is from what, from what you’re saying, the reason incidence two is important from, you know, the, all the compliance methodologies you just stated, but the difference is, is you’ve, if you bill incident two, you get a hundred percent reimbursement versus 85% reimbursement. So it’s really a, a delta of 15% from Medicare with respect to the incident two. Is that right?

Keith Hustak (06:32):
That’s correct. Okay.

Conrad Meyer (06:33):
That’s correct. And that 15% could be a lot over time.

Keith Hustak (06:38):
It can be, yes. and, and, and I think you, you know, we’ll get into it, but, but there, there’s really pros and cons to mm-hmm. to, to really focusing on that incident to, that extra 15%, which we can get into.

Conrad Meyer (06:51):
And, and that’s, and that’s, that’s the nuances of incident to, and sort of the, I guess the, the pitfalls, right? I mean, you, you have to really watch yourself. So for example, in the, in the example that you gave with the PA following up on the on the blood pressure medication basically if the PA does not follow the initial plan of care, let’s say that PA says, Well, you know, I don’t like blood pressure medication. I’m just gonna DC it and we’re gonna start something new, Can that pa bend bill incident to on the claim form as if the physician had done that, that, that that change And, and

Keith Hustak (07:30):
It is of my, it is of my opinion that that would be extremely risky and therefore no. Right. that that should not be done. Because

Conrad Meyer (07:37):
Under the Medicare benefit manual, it’s, it, it, it, it, it, it states that you need to, you know, follow the, the, the plan of care that was initially established by that, that physician. And I guess the, the thought behind that would be that they don’t want, they, meaning, I guess from a quality standpoint, they don’t want a PPPs to sort of decide to go rogue, I guess, if you will. Right. And with, without having the, the physician having a little bit of oversight with respect to that, that patient.

Keith Hustak (08:08):
Yeah. I mean, that, that’s, I think we could, we could theorize as to why they have this, this, these crazy kind of rules and regulations, but that, that probably has something to do with it when this law was established back in the day. Absolutely.

Conrad Meyer (08:21):
Yeah. And, and I think when you look at it, when you, when you sort of get in the weeds and you look at the way healthcare delivery was started, I mean, back in the sixties and the seventies, I mean, you would have a lot of solo practices that you had a lot of nurses, and you had a lot of even spouses helping out the physician, you know, take blood pressure, help intake and so forth. And, and then, and then as we evolve to present day, now you have a tremendous amount of multidisciplinary teams. You’ve got pt, ot, you’ve got a’s like your mid levels, like you’re talking about, you’ve, and so you, and so you’re looking at a lot of different, I guess specialties working toward the same goal that are ally repar a part of that patient care. So, so now with, with incident two, I, if you decided to put your toe in the water right, , literally, if you wanted to do that, you have to be cognizant of the compliant issues with respect of of the direct supervision. Now, interestingly there’s been a lot of comment over the years on incident two and, and, and that I’ve, I’ve seen in the federal regs. and basically the, the comment was, what is direct supervision? And, and, and Keith, did y’all get into that in spectrum, or, or, or was that ever a discussion about what, what was, or how do we define direct supervision?

Keith Hustak (09:47):
Yeah, we, we do get into that. Like in, in my lecture we talk about direct supervision and, and generalized supervision and, and whether or not you have to be in the building or, or out of the building you know, just to be transparent, we, we ended up deciding to, because of, of what we just talked about, how difficult incident two billing is, we decided as a system to go away from incident two to not even not even bother ourselves with it because yes, that 15% over time can make up you know, can bring in a lot more revenue, but the risks of it and, and all the things that you have to kind of, you know, cross the t’s and dot the i’s on it, it just wasn’t wasn’t worth the 15% in, in our opinion, right. So that, that’s kind of why we decided that, you know, we should probably go away from incident to altogether. Now we still do, we still do split shared on the inpatient side. We do think there is a great value there on FLI shared which is very similar, but, but still a different term. but we, we decided to go against incident to,

Conrad Meyer (10:54):
And, and, and I understand that, and, and, and, and you’re correct, I mean, following the compliance, you know, with respect to the incident to. and let’s, and let’s break that down. So, so the bill incident two, you’re gonna have to have direct supervision. You’re gonna have to have a, a, an A service that is, or supply that is provided as an incidental part of the physician practice by auxiliary personnel. Now, that could be a, it could be pt, ot, and, and direct supervision, like you were alluding to a moment ago, requires the physician to be immediately available in the practice. Okay? And that could be if it’s a group practice, it could be another physician in that group. but it doesn’t mean that the, you know, the physician is down the hall. It doesn’t mean that they’re in another suite.

It doesn’t mean that they’re on another floor. It need, they need to be immediately available to help that, that, that auxiliary personnel with the patient. otherwise, if you don’t mean, like you said, all that criteria, then you, then you’re not gonna be able to do it. Now, interestingly, on the claim form, when you submit the claim to Medicare or really your fiscal intermediary, right? It’s gonna have the, the, the physician’s NPI number, it’s not gonna have the a’s, it’s not gonna have the PT or the ot. Now it’s just gonna have the physician, because of course, you know, if you meet those requirements, then it’s as if the physician had done the service, him or herself. So, so that’s in, in a nutshell, that’s incident to. yeah, and, and you’re correct about the pitfalls. Keith, I, I mean, I gave a good example at one of my sea beaches about an orthopedic group that I represented that literally had satellite, multiple satellite offices, and for a period of three years or more had sent their a, out to the satellite offices to do e and m visits on patients with no physicians in that satellite office.

So you can imagine when we sat down and we did a, an audit and we found this out, I was like, Whoa, , right? We have a, you know, Houston, we have a problem. Right. You know, I mean, we have a false claim act you know, for sure a false, a false cl FCA issue you know, for these overpayments. And, you know, and, and initially we, we had, then we had to decide what route we’re gonna take. So in terms of how do we repay the government, right? Right. You know, and that, and that, and that involved an internal investigation and involved, you know, let’s, let’s, let’s see where the problem was. How big is the problem and, and what are our options in terms of using the self-disclosure protocol? Do we, do we simply just return to the Mac the delta between the 185%? and ultimately what we did, we, we just did the delta, because what we were seeing before was we gonna have to refund all of those claims. So imagine the, the damage to operating capital, right? if you had to refund three years of claims for those allied offices and then rebuild them. So absolutely. I mean, it is go,

Keith Hustak (14:02):
I was just gonna say, I, I think when I, again, across the country, when I talk to my peers, colleagues I think the biggest and misnomer is people think you can build incident to simply by seeing the patient and sending the note to the doctor to, to say, to sign off and say, Yep, I agree with the the, the plan of care. And, and people think, Okay, I can build incident to. And that is not incident to. And I think it that case you just talked about where you know, you get these like satellite camps now that are, that are pretty big in healthcare, right? Right. you know, they send the a p out and, and again, they think, Oh, what we can send, and I don’t know if this happened in your case, but we can just send the notes, all the physician, they sign off for a test. Right? and, and that’s intimate to. And, and that, that, quite frankly is not, not anywhere near incident. You don

Conrad Meyer (14:54):
That, that that’s exactly, exactly what happened. So the, so, so when we looked at the, at the medical records and we saw the, at a station, and immediately I said, Okay, well, Dr. John Doe, were you at this satellite office on this date and this time? Yeah. And the answer was, well, no. And I said, You know, let’s, let’s do the really honest thing here. Everyone gimme your calendars and then let’s reconcile it with the dates that you said you, you attest to on those records. And all of them were wrong. And so when we saw that for, you know, we did a extrapolation of 30 days, we realized, okay, we have a bigger problem here, . So That’s right. So, I mean, it really was a, a pitfall. but, and, and so let me, let me bring this other other question to you and, and sort of a, what happens if you’re try, say you’re a group practice and you’re doing incident two billing because you want to capture the 15%, you know that the a hundred percent, but you’re paying your mid-levels on production. How, Ooh. I mean, do you see the problem there? So, yeah, so how I, I mean, because the claim form has the NPI of the physician there, I don’t know of a way to track production. So if that’s the case, have y’all ever, ever heard of that? Just curious if that’s ever crossed your mind on a comp model on a different side, if you’re paying your, your, your a on a production base.

Keith Hustak (16:22):
Yes. Huge issue across the nation in a world I think every conference I go to, there is somebody who is either speaking about this or is, is raising the concern of how do we, how do we you know, drive performance out of apps but yet give them credit when, when credit is due. And so there, there are certain things you can do in Epic where you, you, it’s called a Ghost Code. Epic, by the way, is a electronic health record that we use, I think is probably still the number one electronic health record out there

Conrad Meyer (16:55):
It is today. We, we have a lot of it down here too.

Keith Hustak (16:58):
Okay. Okay, great. but you can put in a ghost code, basically. So if, if you are that practice, as you mentioned, you know, the scenario would be that, you know, you, you wanna do incident two billing, you feel good about it, that you have the right processes and protocols in place. Mm-hmm. that when that a p sees that patient, you would actually drop a, a ghost code in, and that ghost code then can be filtered out on the back end, and then you can give credit to the a p on a productivity basis. So,

Conrad Meyer (17:26):
So the ghost code would not go on the, on the, on the CMS 1500, It would go Correct. Okay, I see. I see.

Keith Hustak (17:31):
Correct. It’s, it’s just all in the background. Got it. now we, we are I I, I think I remember the latest literature and studies and is that roughly about 50% of the country have, have ATPs online productivity models, and 50% have them on more salary model. Mm-hmm. , we’re on that salary model side of things. So as, at this point, we don’t have to kind of worry about that, but as a, as a leader, I wanna start driving more performance and allowing, aligning kind of our a with our physicians. And so I’m forever looking at, you know, when we turn this on, how are we gonna credit the aps? I, I said that we don’t do incident two, which we do not, but where this really comes up, Yeah. is in the, in the inpatient world when you’re, when you’re doing like split share billing because again, you have to give credit to the aps when they’re doing that work, so,

Conrad Meyer (18:29):
Got it. And, and, and so when, and we’re gonna get the split shared in just a second. My, my, I guess the question I would have is if I’m a group, right? And I’m look, and I’m hiring a and I’m looking at comp models, what resources are available to determine salary based on specialty? you know, where do you, where does one go to look for that?

Keith Hustak (18:50):
Yeah, I, I think the, probably the, the, the big three are you know, a gmma mgma. And then the, the biggest one I think that we use is Sullivan Cotter. Yes. which is a consultant group. And, and they have something called the NA National a p Advisory Council. i, I really think Sullivan Cotter is, is really gonna have probably the best, most robust data in the next couple of years that they’ve been working on it. And so we, what we do basically is we take kind of a blended survey of, of those three, and I think we might even have one more. and then we look at, you know, salary information, productivity information, and that’s kind of how we do our benchmarks.

Conrad Meyer (19:36):
Gotcha. I, I think that’s, I mean, let, lemme tell you, I can’t tell you you know, now spectrum’s at a whole different level than, you know, than than a lot of groups down here. We don’t have large systems like the, the two large, this is, we have down here Oxner and lcmc but but not, not like you have up in, in Michigan. So you have a lot of, you know, midsize large groups, you know in, in specialties, and sometimes you ha you still have some, some small medium size groups in this market. So it’s diff a little bit different. But, you know, I know that there’s challenges because a lot of these doctors wanna hire mid-levels and they’re just scratching their head, Well, how do we do this? Especially if we wanna do incident to. So, so that’s a good, that’s a good thank you for those resources. That’s really a helpful thing. mm-hmm. , let’s get this split shared now, cuz you mentioned Split Shared. Sure. And you and I actually had a, on our, on our, our recent conference with Apex, you and I had a, a back and forth about this. So yeah, tell me what, what is your understanding of Split share and how does it relate to incident two and why do you think it’s important?

Keith Hustak (20:43):
Yeah, so the, the way that we teach split shared, and again, I’ll, I’ll give a a kind of a, a case study to kind of bring it all home, but is, is that we utilize this on the inpatient side of things. And it really, you know, the term is really a misnomer cuz when you think split shared, I think, I think shared is what makes people get confused about this. And I, and I go back to that, what we talked about earlier, which was, which was the, the term around a test, right? There’s a lot of the testing that goes on in the inpatient world, and that, that largely is because of medical staff bylaws, because like here in the state of Michigan, we have to have physicians who you know, see the patient every 24 hours. And, and and, and so, you know, because of that, they, they are always attest to what the A p p saw, right?

and I, I bring that, cause that’s very important because a split shared, again, is not just a testing. So the way that we teach Split shared is this, you have an A P P who sees the patient, right? And writes a note mm-hmm. the physician then comes behind the patient. and again, I’ll, I’ll give a case study on this so you can kind of bring all together, okay, the physician comes behind the patient and you know, can’t just say I agree with the plan, but literally has to do elements of the history, elements of the exam has to be in the room and it has to discuss the plan of care. And we teach it in a separate note. So we, we keep it completely separate. It. If, if those things are done and the physician sees the patient on the same day, which by the way is different than residents, this is where it gets again, very complex, right?

That’s different than residents. But on the same day, then you can do a split shared bill. So here’s the example really quick. Okay. I used to, I was a big, I’ve done many things in my career, but, but one of the things I did, my first love in medicine was orthopedics. And so you know, I would often come in and see the patient who maybe, you know, fell down. let’s say they fell down, break dancing, right? They’re crazy, 70 year old and, and they’re at a party and they’d fall down, extreme hit pain, you know, they’re run into the er, right? And the ER physician, you know, calls me in and, and so my job at this point is to see the patient look at the x-rays and, you know, decide whether or not we’re gonna admit them, that sort of thing.

I see the patient I see on the, on the, on the X-ray, Yeah, this is a definite, you know, greater TRO fracture, whatever you wanna call, but it’s, if a fracture’s gonna require surgery mm-hmm. I document in my note, you know, saw the patient, did my exam, you know, let’s say the patient has shortening of the leg and external rotation, all the things that we see you know, plan to go to the or in the morning, right? Right. The physician then comes in behind me and again, has to actually physically go into the room, has to do with the physical cause they so lay their hands on the patient. Now, what’s a little bit nebulous about split shared is that they really don’t say, and maybe you can correct me I’m wrong about this, but they really don’t say how many elements you have to do of each. So it’s not like you have to do two elements of a physical exam or, you know, it’s, it’s just that you have to do an element of each one.

Conrad Meyer (24:13):
That, and that’s, and that’s absolutely true. And the proc, the Medicare pro benefits processing or claims processing manual, it doesn’t say that. It just says that it has to be a substantial portion of the e and m visit, the evaluation of management visit. And, and you’re right that both the physician and the a must be together, doing it together, whether that’s the history, the, the examination, rear review of systems, the whole bit.

Keith Hustak (24:36):
Yep. So again, that physician then is doing elements of the history, elements of the exam, Right. and then plan of care, and then they sign a note. And at that point, because we, we’ve met that requirement of doing it within the same day then you can bill split share, which means, again, essentially you’re billing under the physician and giving credit to the physician. And again, this is where if you are on a productivity comp model, we wanna somehow give credit to the AVP who, who saw that patient, you know, just to give them them something.

Conrad Meyer (25:08):
So that that’s, So they’re gonna doc real quick, Keith, they’re gonna document that in the, in the note, Correct? I mean, so in other words, correct. From a documentation standpoint, you’re having the a p document that Physician X was in the room I evaluated x I did X physician in his notes gonna say I was with a so and so in the room and I did X, Y, and Z. Is that correct?

Keith Hustak (25:31):
That’s correct. The, the physician has to be, you know, laying their hands on, on the patient. So let’s, let’s go back to a testing really quickly. What you can’t say is agree with a’s plan, right? You can’t say agree with plan, go to the or, right? You can’t say you know, I look at the X-rays and completely agree. You know, go to the ar it’s like you, you literally have to write a note. and that’s where I think the shared part gets a little bit the name, the naming is just a little bit love a misnomer. Cause you really, we teach it, you have to really be, be writing a separate note having your own kind of clinical plan. You can now, you can say agree with a P but you still have to do elements of those of that exam finding in the plaintiff

Conrad Meyer (26:17):
Care. And just to be clear, so everyone understands when we say split shared, all that really means is, I mean, we we’re talking about the process of split shared, but it means we’re billing that as an incident to claim. Is that, is that right Keith?

Keith Hustak (26:31):

Conrad Meyer (26:31):
We meet, don’t if we meet that requirement,

Keith Hustak (26:33):
Yep. Yes. Now I don’t teach it that way. but you’re right. I what I I always try to keep them separate just, just to keep it very simplistic for people, right? So again, this is just the way I teach it, The way I teach it is outpatient is incident to inpatient is split shared. And yet, and you are right though you were, you really are billing then under the physician,

Conrad Meyer (26:54):
Right? You’re getting, you’re getting the hundred percent on that, on that visit on, on that e m visit.

Keith Hustak (27:00):
Yep. Absolutely.

Conrad Meyer (27:02):
So let’s, that’s a, that’s a good explana. I love the example. I mean, I think that’s a very spot on example. That’s a good way to see it. I know that the claims processing manual also talks about various settings. So for example, you can’t do it at nursing facilities or sniffs and critical care settings. correct. But it does, it does say you can do it outpatient as well. so it just depends on the setting. and as long as you avoid the sniffs and the critical care and the nursing facilities, you’re gonna be fine on the shared split shared. but, but let’s go to the, to the consequences. So really the, the fall out,

Keith Hustak (27:36):
Can I back to the Yeah, go ahead. Go back. One, one thing you just said that I, I think is an interesting yes point.

Conrad Meyer (27:41):

Keith Hustak (27:42):
Ahead. You, you can do this on the outpatient side. Yes, you can. But here, here’s what, here’s what we teach, and I think if you, some of the experts out who are out there also teach it this way, that if you’re doing a split shared visit on the outpatient side mm-hmm. , I just want you to think about this financially for a second. so financially on the outpatient side, and, and, and I’m, I’m making generalities here, but on, on the outpatient side, right? These are people that are not like critically ill typically, Right? Right. meaning that, you know, we don’t need to like, make life saving decisions unlike on the inpatient world.

Conrad Meyer (28:18):

Keith Hustak (28:19):
So if you’re tying up two providers now, so you have, you have a physician and an a p who is seeing two two providers who is seeing that patient, right? Think about financially that that’s gonna be a no-win, right? So that’s why we say we shouldn’t do a, any, we should not be doing a regular bout of split shares on the outpatient side, just surely from a financial perspective, having said that,

Conrad Meyer (28:44):

Keith Hustak (28:45):
If, if this physician is needed, you know, that there’s something going on where the physician is absolutely needed, then absolutely go ahead and, and, and we feel comfortable doing split shared, but it should not be a regular practice. So that’s, and we,

Conrad Meyer (29:00):
That’s from a resource allocation standpoint is what you’re saying.

Keith Hustak (29:04):
That’s right. That’s right. If it, cause if you break down like how much margin you make per visit, again, now you have two providers which are highly paid doing a visit for a a person, Right? it should not be a regular practice. Again, there are, there are some specialties out there that still do it. and don’t allow that a to work top of license or top of competency. but again, financially, it just does not make a ton of sense. And, and you’re right. You’re not on the inpatient

Conrad Meyer (29:31):
Side. Right? Right.

Keith Hustak (29:32):
It, it does make sense because that’s what we have to do those things on the inpatient side.

Conrad Meyer (29:36):
Well, cuz the e and m levels are gonna be higher acuity, so you’re gonna get higher level reimbursement on like, for example, a level four, level five, Right. Than say a level three or level two on an outpatient side.

Keith Hustak (29:48):
That’s right.

Conrad Meyer (29:49):
So very interesting. Very, thank you very much for that. well now let’s, let’s cross over the bridge to, to the danger zone, right? Let’s get to the mine field. So if you break compliance, then like in, in my example of the orthopedic practice that didn’t do this for three years, suddenly you have false claims issues. And interestingly you have an overpayment that of course the government’s gonna want that back. yeah. And, and each individual claim is subject to an FCA penalty of five to $15,000, along with a cmp, a potential CMP civil monetary penalty of up to $11,000. So you’re looking at 20,000 potential $20,000 penalty per claim. How many claims you think it filed a day in in Keith? How many claims you think it’s, Oh,

Keith Hustak (30:37):
You know, I, I don’t, I really have no idea.

Conrad Meyer (30:41):
Over 10 and I over over 10. Oh yeah. Over a hundred.

Keith Hustak (30:45):

Conrad Meyer (30:46):
. You know?

Keith Hustak (30:47):
Yeah. I mean, it, it’s, it’s a lot. I would say though that, I mean, I think you bring up really good point. It’s, it’s not, think about this, it’s not just like one auditor, like coming in and doing audits. Like, I mean, we have like OIG and revenue audit contractors and the, the heat team I think, which is healthcare fraud prevention, enforcement, team zone, program integrity contractors, like, so I, I bring it up because it’s, there are so many different forces and their job is to find problems

Conrad Meyer (31:22):
That that’s how they make money. I mean, Rack and Zick, the rack and Zick, the one you just me mentioned, Rack and Zick, they don’t get paid unless they find money.

Keith Hustak (31:32):
That’s right. And, and that’s, I think the, the cautionary tale here is even if there is no intent to do harm or intent to do wrong, these, these organizations are out there along with our government and, and, and they’re gonna, eventually it’s gonna catch up to you. They’re gonna find it. So that’s why it, you know, getting back to you asked earlier like, why is it so important? That’s why it’s so important.

Conrad Meyer (31:55):
Well, let me ask you this. So I, your, your spectrum has made the decision to not take the incident to billing route, which I think, you know, you know, compliance stand stand wise, it’s, it’s a tough, it’s a tough road to hope. I mean it’s, it’s, it’s definitely a, it’s definitely a, a you have a learning curve of you have a learning curve, a steep learning curve. If you’ve never dealt with this before, if you’ve never heard it before, what would you tell groups based on your experience, your your knowledge of, of this incident to billing? What would you tell, what would be the best advice you would give groups who are looking to decide whether or not to do the incident to or capture that 100%?

Keith Hustak (32:32):
Yep. Good question. So I would, I would tell ’em this. If, if you decide that you, that you know, maybe you’re a smaller practice and you really need that 15% revenue, you gotta put programs and things in place to make sure that you’re doing kind of your own internal audit to make sure that that, that there’s a, a system in place that, that really helps you to reduce that risk mm-hmm. of, of involvement of those organizations that we just talked about. because if you don’t, again, it, it at some point it will catch you. so that’s probably what I would say. Again, we made the decision not to you know, I I think that we had some pretty close calls that spectrum that’s been in the news and, you know, nothing was, was found or substantiated, but, you know, when we started looking into this, it was like, this just is not worth it for us. Right. And then they, I was not in my role at the time and I was just getting into my role. They were looking at me as, as to, you know, what, what are your thoughts? And again, going across the country and meeting with, you know, large leaders and I think there’s a lot of institutions probably our size that have also made that same stance. Right. So just kinda give you a little bit perspective there.

Conrad Meyer (33:47):
That’s very interesting. And, and, and again, yeah, if you’re, if you’re not, if you’re not up to speed on, on what it involves and how to set up an internal audit process for compliance purposes a agreed. You might be literally waiting into a mine field of, of, and you just don’t even know.

Keith Hustak (34:05):
Oh, yeah. And, and that’s where they can probably use your services, right? Because you guys can probably set up like some internal audit stuff. That’s right. Quite frankly we’ll be well worth the money. we without a doubt, so.

Conrad Meyer (34:18):
Well, I appreciate that. Yes. We, we do, we, we, some I wish a lot of times, Keith, that, that I would get, we would get the calls from the providers beforehand. A lot of times, I mean, I call myself Smokey the Bayer sometimes because all I do is put out fires. Right? Right. And, and, and if, if simply providers would just call and say, Look, you know, cuz a lot of providers we know, and I mean, I know Rory can attest to this too, they hate lawyers hate us. And, and, and like inherently, like we don’t like lawyers, We all they do is bill charges and we don’t like them. Haha. So, but, but what I tell ’em is, is that we’re, we are, we are literally aligned with you, you know, paying a little bit for our services now could save you a tremendous amount of money and, and headache, you know, later. So Absolutely. You know, it, it’s just, you know, but, but, you know, we’ll, we’ll, we’ll try to shift the paradigm, you know to see if we can, we can get that corrected down the road. But, but all these are fantastic points and, and I, I want to thank you. any final thoughts, Keith, to, to the listeners with respect to incidents who,

Keith Hustak (35:28):
Yeah, just, just final thought. I think you, you hit it on the, on the head in terms of, you know, I think prevention is, is critical. and we talked about kind of the benefits and risks, you know, the, the, the 15%. I would just say, you know, really cautionary tale, is the 15% really worth it? In our case it wasn’t. But I understand there’s different avenues and things out there that, that, you know, practices can look at. If you do decide to do incident to, you know, please have an, an internal audit pla practice in place. That’s what I would

Conrad Meyer (35:58):
Say. Well, fantastic. Well, Keith, we thank you everybody. Keith Hustak from Michigan. He is the Vice President of Advanced Provider Practice and vice president of operations at Spectrum Health. We thank you very much for coming on today and I think that’s gonna wrap it up for us, Rory. Let’s go ahead and close it out. thank you everyone, and we’ll hopefully see you on our next episode of Health Law Talk at Chehardy Sherman Williams. Thank you.

Rory Bellina (36:25):
Thank you for listening to Health Law Talk presented by Chehardy Sherman Williams. For more information or to contact us, please visit our website linked in the description below. Also, please be sure to subscribe to our podcast and follow us on Facebook, Twitter, LinkedIn, in YouTube – links in the description below. Thank you for listening.

How can Incident-To billing bring more revenue to your practice? When physicians rely on advanced practice providers (APPs) to maximize services to patients, reimbursement from Medicare dips to 85% percent of the physician’s professional fees – which can add up to a big loss of revenue. In order to maximize a practices’ revenue, practices can bill these APPs as “incident-to” capturing the full 100% of the professional fee instead of 85%.   The trick is how to comply with CMS guidelines in order to use “incident-to” billing for your practice.  Join us for Episode 102 of our new podcast Health Law Talk as we interview Keith Hustak, VP of APP at Superior Health, to discuss his experience regarding Incident-To and the pitfalls v. positives of seeking reimbursement of the 100%.

Health Law Talk, presented by Chehardy Sherman Williams, one of the largest full service law firms in the Greater New Orleans area, is a regular podcast focusing on the expansive area of healthcare law. Attorneys Rory Bellina, Conrad Meyer and George Mueller will address various legal issues and current events surrounding healthcare topics. The attorneys are here to answer your legal questions, create a discussion on various healthcare topics, as well as bring in subject matter experts and guests to join the conversation.

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