Do you use Midlevel providers in your practice?

The Texas Medical Association recently posted an article that some health plans have adopted a new policy regarding services of nonphysician practitioners(NPPs). Can anyone offer any information that they may have about this? Have you started the process of credentialing your midlevel providers directly with the insurance companies?

Thank you!

That is a great question. I am a Midlevel Provider (NP) in Oregon. I have a solo practice in rural Oregon. I am directly credentialed with almost all of the local insurance companies. I do not credential with the Medicare advantage plans of course because here anyone under 18 is enrolled in the Medicaid plan.

Honestly, my contracted rates are the same as the local physicians in our IPA. If I were an FNP managing Medicare patients this would not be the case. There is no incident to billing in my clinic. I have lists of managed care patients assigned directly to me as well as participating in the PCPCH program.

The only program that I have recently given up participating in is the Rural Health Clinic designation. My CCO contracts were such that there was not wrap around payments for services and the physicians that I have employed did not stay. Physician supervision is a requirement for that particular program.

I cannot speak to Texas contracting, but here in Oregon direct contracting has worked out well.
Lisa Callahan CPNP

Thanks for your response

We are a practice in CT. Our midlevels are all credentialed and we do not bill incident to as they are really functioning independently. Most payors give a % of the full rate for the mid-levels though.

Oregon passed into law 2016?? a payment parity law. NP and PA are to be paid at 100% of MD for the same CPT code. It continues to specifically cover option to lower MD reimbursement to adhere to the 100% mandate

Exceptions are Medicare, group contracting associations (IPA??) and insurance companies unter Federal insurance regulation and not State.
Off the cuff that is Aetna and any company that manages an employer privately funded insurance.

We are a practice in AZ. We bill the NPs and PAs independently. We get a percentage of MD rates for them (including for the cost of vaccines, which is really a bummer!!!)… We are thinking of following the ‘incident to’ billing, would anybody be able to give any direction?

You need to file a Hassle Factor Form with the AAP immediately.

The (typically) 15% discount NP/PAs receive from payors should only affect E&Ms as a rule. Taking 15% off of a vaccine because an NP ordered it is unethical, immoral, and should be considered organized crime.

YES!!! We are at the mercy of this organized crime.

Rajeev Agarwal, MD

Agave Pediatrics

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