US Attorney for the Western District of Michigan Mark Totten announced that Edward W. Sparrow Hospital Association d/b/a Sparrow Medical Group, Sparrow Care Network, and Sparrow Health System located in Lansing (collectively “Sparrow”) have agreed to pay $671,310 to resolve allegations that they violated the False Claims Act by misuse of “incident-to” billing. An “incident-to” billing provision allows an Advanced Practice Provider (APP), including nurse practitioners and physician assistants, to treat a patient but bill the encounter under the physician’s name and reimbursement rate if certain criteria are met. Those criteria include the presence of an on-site doctor, that the physician performs the initial visit for the patient, and that the physician establish the patient’s diagnosis and treatment plan during the initial visit. If an APP appropriately performs a service “incident to” a physician’s oversight, the physician or their healthcare practice may submit a claim for 100 percent reimbursement for the patient encounter, as opposed to the 85 percent reimbursement rate if the APP billed services under their own billing number. The United States alleges that Sparrow improperly billed services under a physician’s name and reimbursement rate where the services were rendered by mid-level providers at Sparrow’s locations where the criteria for “incident-to” billing were not met.
