2017 HSC Section 2 - Practice Management

The first independent model for effective use of

advanced practice providers is limited independent prac-

tice. This model is based on ‘‘incident to’’ billing, which

is a type of physician extender billing practice for select

patients. Incident to billing is a Medicare provision that

allows midlevel providers to perform independent care but

bill at 100% reimbursement if certain criteria are met.

9,10

Stipulations for incident to billing include that the patient

must be an established patient within the scope of the

physician’s practice. Billing utilizes the physician’s billing

number and the physician must be on site.

The ideal

patients for limited independent practice and incident to

billing include follow-up patients and routine postoperative

patients. The low acuity and established nature of ‘‘incident

to’’ patients promotes a gentle transition between collabora-

tive and independent practice for physician extenders. The

model of limited independent practice differs from the

other independent practice models because it utilizes the

physician’s billing number for higher reimbursement rates.

However, only select patients meet criteria for this model

thereby limiting the scope of practice.

Partial Independent

In partial independent model utilization, the physi-

cian extender conducts patient encounters by himself or

herself with the physician available in the office. The

partial independent model promotes autonomy of the

advanced practice provider while allowing the capacity

for the physician to provide assistance on complex

patients. This model is advantageous because it allows

for increase in patient encounters without the addition of

another otolaryngology physician. Ideal patients include

walk-in, follow-up, routine postoperative, and low acuity

new patients. Reimbursement rates for patient encoun-

ters are less than physician reimbursement due to

utilization of the midlevel provider billing number. How-

ever, lower reimbursement rates are offset by the lower

salary rates of physician extenders. Although the partial

independent model is ideal for the busy practice, the prac-

tice must have available office space and the staffing

capacity for increased patient load.

Near Complete Independent

The final model is near complete independent prac-

tice. In this setting, the advanced practice provider will

practice with the supervising physician off site. The phy-

sician extender will function under a predetermined set

of guidelines and practice protocols. Periodic chart

reviews are often performed by the physician but the

degree of required supervision is regulated by the state.

Although the supervising physician is out of the office,

he or she is available for questions or situations that fall

outside of the practice parameters. This model is advan-

tageous, especially in solo or small group practice,

because it allows utilization of office space while the

physician is offsite or in the operating room. Again,

reimbursement is based on the physician extender bill-

ing number but provides the best utilization of resources

by preventing unused office space.

Application and Advantages of Utilization

Models

Midlevel providers are useful adjuncts for practi-

tioners who are unable to meet the clinical demand of

the community they serve. Busy solo or small private

practices may benefit from physician extenders employed

under the independent model of practice. Advanced prac-

tice providers in this setting may improve practice

efficiency and increase revenue by managing walk-in

appointments, low acuity or postoperative patients, and

situations where the physician is called to an emergency

during clinic hours.

A midlevel provider in this situation

may function through limited, partial, or near complete

independent practice, depending on the patient, acuity of

the situation, or location of the physician. It is important

to consider that the same advanced practice provider has

the flexibility to function within all of the model practice

patterns described during the same day or over time as a

practice grows and its needs change.

The addition of a midlevel provider is more econom-

ical

than adding another physician partner.

Reimbursement for advanced practice providers may

vary based on contractual agreements with private insur-

ance; however, is generally at 85% of the fee schedule

amount for physicians.

10,12

Although reimbursement

rates are moderately reduced compared to physician

rates, the compensation rate of midlevel providers com-

pared to physicians is dramatically different.

Dierick-

van Daele et al.

found that ‘‘direct costs plus productiv-

ity costs were significantly lower for nurse practitioner

consultations’’ compared with consultations of general

practitioners. According to a national survey, the average

base salary for advanced practice providers is $80,000

plus addition costs of 25% to 30% for benefits and over-

head.

The annual salary for PAs in otolaryngology

practices is $86,856 versus $90,019 annually for all other

PAs.

Furthermore, adding a midlevel provider may be

easier than finding an otolaryngologist available for hire

particularly in rural settings and as the demand for

healthcare services continues to exceed the number of

specialists trained.

A final benefit for utilization of midlevel providers

is one of improvement in patient care. Patient satisfac-

tion, patient education, and management of chronic

diseases are improved by creating a multidisciplinary team

approach to patient care through the addition of advanced

practice providers in the collaborative practice model.

2,14

Patient education may be improved in areas such as

tobacco cessation or nutrition, especially for patients with

head and neck cancer. In a systematic review of the recent

primary care literature, patient education was found to be

significantly improved when NPs participate in patient

care.

Patient satisfaction is determined in part by time

spent in the patient encounter. Rashid’s integrative review

found that advanced practice nurses had unhurried consul-

tations with a tendency to reinforce messages making the

patient the focus of their attention.

Midlevel providers

may increase the amount of time spent with patients while

optimizing physician efficiency.

The benefit of improvement in patient care may be

best utilized in an academic setting or where the

Laryngoscope 121: November 2011

Norris et al.: Physician Extenders in Otolaryngology

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