Changes are coming quickly for Medicare providers who provide services in hospitals and skilled nursing facilities regarding the use of split shared services. The new rules from the Centers for Medicare & Medicaid Services (CMS) come into force on January 1, 2024.
One of the most significant involves billing when patients are seen during a primary E/M visit by both a physician and a nonphysician practitioner (NPP) such as a physician assistant, advanced practice registered nurse, nurse practitioner, clinical nurse specialist, or other nonphysician provider. Under existing rules, the physician typically bills for the time spent by any number of clinicians to see, examine, consult with, and treat the patient, using an FS modifier to denote the shared charges. Starting January 1st, the listed provider will be the person who spent the majority of time on the patient encounter, which does not necessarily translate into the person who provided the most in-person care to the patient. Critical care visits are not affected by the new regulations.
“Now you have to decipher who the billing provider is, which according to the new guidelines is the person who spent the most time with that patient,” said Shanta Lewis, Product Manager, MDaudit. “It wasn’t necessary in the past to distinguish between rendering and billing providers, so it wasn’t clearly and concisely outlined in the documentation.”
These changes may bring considerable additional work for coding and auditing departments. Claim scrubber software will require updates. Nonphysician practitioners may need to be credentialed with payers to obtain a provider number, and auditing departments will need to adapt workflows to monitor compliance with regulatory changes.
Auditors Will Play an Oversized Role in Compliance with New Rules
While the updated rules can provide greater transparency into care processes and better align reimbursement with the provider who performed the majority of services, providers and care facilities affected by the regulations are understandably concerned. Those concerns include potential impacts on physician compensation, net revenue, day-to-day workflows, and the traditional care model where each team member plays a unique role in the overall experience.
The changes will upend physician/NPP interactions, with uncertain implications. However, there’s no doubt that coders, billers, and compliance teams will all be affected. Documentation processes will need updating to ensure the proper caregiver charges for the encounter – this includes ensuring time records don’t show overlaps between providers. Since commercial payers often adopt the same rules as CMS, expect this change to split shared services to gain wide adoption.
It will be up to compliance teams to ensure their providers and facilities comply. That starts with robust education on the new rules, both for themselves and for coders and providers. Then, auditors must monitor compliance – including claim scrubber edits – to ensure that services are captured properly and supported with the appropriate documentation.
Technology can also help, in the form of internal audit workflow tools that include the ability to separate the servicing provider from the billing provider during the audit process. That granularity allows auditors to look for places where the service provider and the service provided do not match. Prospective audits can catch these errors before claims are submitted, preserving revenue. Retrospective audits can uncover providers, departments, or service lines that are not in compliance, pointing to where further education is needed.
Stay on the Right Side of Compliance
Because nonphysician practitioners are paid less than physicians, the evolution of split shared services could have a profound impact on hospital and health system revenues. Federal audit efforts show no signs of slowing, so hospitals and health systems must stay on the right side of regulations to prevent punitive measures and preserve legitimate revenue.
A robust solution that provides a single auditing platform and advanced dashboards to uncover insights quickly can help audit departments adapt to these new rules.
