After you pay for care using health insurance, the insurer reimburses your provider. Blue Cross Blue Shield of Michigan pays providers like nurse practitioners and physician assistants at a lower rate than more highly-trained providers like physicians.
But at some practices, providers who are not doctors but are supervised by one get reimbursed at that doctor’s higher rate. This is often called “incident-to” billing.
Earlier this year, Blue Cross announced it will phase out this practice beginning September 1. Dr. Amy Milewski is BCBS of Michigan’s Interim Chief Medical Officer.
“Today, some of the billing gets what I would say is ‘nested’ or billed under a provider that is not delivering the care,” Milewski said.
Milewski said this means patients may be paying top dollar for care delivered by a physician, even when that care is delivered by a provider with less training, and the new policy aims to end that.
But Dr. Eric Bryant of Cereal City Pediatrics in Battle Creek says that’s not necessarily fair for clinics that use team-based care.
“If we're within the four walls of the practice, you have the overseeing physician for the day going through these patients, patient by patient,” Bryant said.
Bryant said that even when a doctor isn’t directly seeing the patient, they are often still heavily involved in patient-care decisions. He said billing under the doctor that oversees all the care can reduce overhead costs for clinics that employ a high number of non-physician providers.
“It's leaving us to scramble in our office to find ways to do a lot of cost cutting — which, we're already fairly efficient,” Bryant said.
He feels the policy change will make it harder for many smaller, private clinics to compete with larger health systems that can afford to employ more physicians.
He emphasized that larger health systems like hospitals are also able to charge facility fees — a practice that BCBS itself has called “unreasonable”.
In a statement, the Michigan State Medical Society said they’ve heard from a large number of physician and non-physician practitioner groups who are concerned about the policy change.
Studies show that a growing number of primary care clinics are employing nurse practitioners and physician assistants to fill gaps amid physician shortages. The Bureau of Labor Statistics ranks nurse practitioners as the third-fastest-growing career in the nation, and physician assistants the tenth-fastest growing.
Milewski said Blue Cross understands that this will change things for smaller clinics and facilities that employ a large number of non-physician providers, but the insurer believes the move is necessary to increase transparency.
“The intention is really like I said to ensure that we are aligning — we're expanding opportunities for advanced practice providers, but there is also a recognition that the training for a physician and a nurse practitioner is different and that we are aligning our payment tied to those policies,” Milewski said. “And this is consistent with other plans as well as how [the Centers for Medicare and Medicaid Services] adheres to payment. So that's how we are looking at it.”
Bryant said currently, Cereal City Pediatrics employs six physician assistants and four physicians, and he estimates as many as half of the clinic’s patients are covered by Blue Cross Blue Shield. He said he and other members of his practice aren’t exactly sure yet how the policy change will impact their finances — but they’ve started planning ahead.
“If we're going to get reimbursed less on these patients, and especially if other insurers are also going to be following CMS guidelines and following the steps that Blue Cross [is] taking, then it's going to lead to then our employees having to essentially try to see more volume of patients in the office to try to make the same numbers at the end of the year,” Bryant said.
He said he’s concerned the policy change will lead to burnout and reduced quality of care.
Milewski said the first phase of the policy, beginning Sept. 1, will still allow providers to bill through a supervising physician as long as they add a modifier code. Milewski said the policy will be implemented in two phases to allow advanced practice providers that aren’t already in-network with Blue Cross to become enrolled.
“Beginning in March, we are asking for any provider that is actually able to bill us directly — so, if they have an NPI, which is a provider identification number, we are asking that they then bill us directly,” Milewski said.
The policy also includes specific guidelines regarding behavioral health providers. The Michigan chapter of the National Association of Social Workers said the policy will reduce access to care and weaken the behavioral health workforce. The group has launched an email campaign and organized several rallies in an effort to “push back” against the policy change.
