When speech-language pathologists became eligible to sign up as independent providers with Medicare in 2009, it was a mixed blessing. Many people worked for years to ensure that speech-language pathologists would be recognized as the highly trained, licensed professionals we are. Obtaining the ability to bill Medicare under our own provider numbers finally cemented our professional status as health care providers within their system.
Inevitably, the ability to enroll in and bill Medicare, however, came with a number of obligations and restrictions. Now that we can be Medicare providers, we must be whenever providing services to a Medicare member (see my previous post on the lack of an opt-out option for speech-language pathologists). In addition, the paperwork involved in joining Medicare can be somewhat overwhelming at first.
Some speech-language pathologists are forgoing Medicare provider status, opting to bill their work as “incident to” physician service instead. While this is a legitimate, legal option for Medicare billing, it has implications for speech-language pathologists as independent health care professionals and I believe in the end it endangers the professional recognition we have worked so hard to achieve.
So, what is "incident to" billing?
"Incident to" billing occurs when a health provider (such as a speech-language pathologist) is paid by a physician to provide services that are then billed by and under the NPI of the physician. Under this system, the speech-language pathologist does not have to be an independent participating provider with Medicare and in fact does not even need to have a license (though they must meet other criteria for speech-language pathology provider status).
This sounds like a great work-around to the hassle of obtaining Medicare provider status, but there is a huge trade off. Under the "incident to" model, the therapist needs to be under the "direct supervision" of the physician during all of their work. This means that there must be a physician in the office suite whenever the speech pathologist is working with patients. If the MD you're working for goes to a conference for a week, you can't see patients.
In addition, the supervising physician must be immediately able to come in to "help" whenever needed. They also must "take responsibility" for the treatment provided. The entire system is designed around the concept of the treating provider being a dependent, para-professional who is not allowed to provide treatment without the presence of a physician. Unfortunately, if substantial numbers of speech-language pathologists decide to forego independent provider status and submit to the "direct supervision" requirements inherent to an "incident to" billing status, Medicare may reconsider their decision to allow us to become independent providers. Widespread use of "incident to" billing is a threat to the gains we have made as a profession to prove our inherent worth.
As a speech-language pathologist, you can still be hired by a physician practice, bill under your own provider number and then “assign” your payment over to the practice. That allows you to take advantage of the benefits of being employed (where someone else is dealing with the hassles of billing), while maintaining your professional status and autonomy.
"Incident to" billing certainly has a place within the big picture of the healthcare structure. It was useful in allowing me to work with two physician groups when I was in private practice to provide stroboscopic examinations to their patients. For the day-to-day operations of evaluating and treating speech-language disorders, however, an "incident to" arrangement invariably leads to a hobbled ability to effectively execute your professional autonomy. This bears consideration before deciding that becoming a Medicare provider is too much trouble. What's a few hours more of paperwork if it gives you a career of greater self-determination?
Medicare Benefit Manual
230.5 - Physical Therapy, Occupational Therapy and Speech-Language Pathology Services Provided Incident To the Services of Physicians and Non-Physician Practitioners
(Rev. 179, issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14