Part 1: Split/Shared Billing for Advanced Practice Providers (APPs): A Discussion with Jodi Nayoski and Andrea Ferrari of Pinnacle Healthcare Consulting

Episode Date: May 31, 2023

In this episode of Stark Integrity, Bob Wade (“Captain Integrity”) is joined by Jodi Nayoski and Andrea Ferrari of Pinnacle Healthcare Consulting to begin a two-part discussion on split/shared billing for Advanced Practice Providers (APPs).

Drawing on their practical experience, Jodi Nayoski and Andrea Ferrari provide insight into the regulatory requirements, operational challenges, and compliance risks associated with this increasingly important billing methodology.

Understanding Split/Shared Billing

Jodi Nayoski and Andrea Ferrari explain that split/shared billing allows both a physician and an APP to contribute to a patient visit and, when specific requirements are met, enables billing under the physician’s National Provider Identifier (NPI).

They note that:

• The model is designed to recognize team-based care
• It can impact reimbursement depending on how services are billed
• Strict rules govern when physician billing is appropriate

Because of its complexity, split/shared billing must be approached with precision and consistency.

Why Split/Shared Billing Creates Compliance Risk

A central theme from Jodi Nayoski and Andrea Ferrari’s discussion is that split/shared billing is a high-risk area if not properly managed.

They emphasize that:

• Requirements are detailed and frequently updated
• Misinterpretation of rules can lead to incorrect billing
• Improper use may create overpayment and False Claims Act exposure

Given the financial implications, regulators pay close attention to whether organizations are meeting all required elements.

Physician Involvement Requirements

Jodi Nayoski and Andrea Ferrari highlight that physician involvement is one of the most critical aspects of compliance.

They explain that:

• Physicians must perform a substantive portion of the visit
• Their participation must meet defined regulatory thresholds
• The level of involvement must be clearly documented

If these requirements are not met, billing under the physician may not be appropriate.

Documentation Expectations

Another key takeaway from Jodi Nayoski and Andrea Ferrari is the importance of clear and complete documentation.

They note that:

• Both the physician’s and APP’s contributions must be documented
• Documentation must support the billing methodology used
• Inconsistent or incomplete records create compliance risk

Even when care is appropriate, documentation gaps can lead to defensibility issues during audits.

Evolving Regulatory Landscape

Jodi Nayoski and Andrea Ferrari also emphasize that split/shared billing rules continue to evolve.

They explain that:

• Recent regulatory changes have clarified certain requirements
• Organizations must stay current with CMS and payer guidance
• Policies must be regularly updated to reflect new rules

Staying informed is critical to maintaining ongoing compliance.

Operational and Training Challenges

A practical focus of the discussion is the operational complexity of implementing split/shared billing.

Jodi Nayoski and Andrea Ferrari explain that organizations must:

• Align clinical workflows with billing requirements
• Educate both physicians and APPs on expectations
• Ensure coordination between clinical and revenue cycle teams

Without proper training and alignment, organizations may struggle to apply the rules consistently.

Practical Takeaways

The key takeaway from Jodi Nayoski and Andrea Ferrari’s insights is that split/shared billing requires disciplined processes and strong oversight. Organizations should:

• Understand and apply current regulatory requirements
• Ensure physicians meet involvement standards
• Maintain clear and consistent documentation
• Train providers and staff on proper billing practices
• Monitor and audit split/shared billing regularly

Final Thoughts

This episode, through the practical perspectives of Jodi Nayoski and Andrea Ferrari, highlights that split/shared billing is both an opportunity and a risk.

When structured and executed properly, it can support team-based care and appropriate reimbursement. However, without careful attention, it can create significant compliance exposure.

This Part 1 discussion lays the groundwork for understanding the complexities of split/shared billing and sets the stage for further insights in Part 2.

Click here to listen to this Stark Integrity Podcast Episode:
https://podcasts.apple.com/us/podcast/part-1-split-shared-billing-for-advanced-practice-providers/id1588939373?i=1000615090610&l=fr-FR