Incident-To Billing Fraud: Whose Work Is Under the Physician’s NPI?

Incident to billing fraud occurs when a practice knowingly uses a physician’s billing identity to collect payment for services that fail Medicare’s incident-to conditions. The patient may have received health care, but the claim can tell a different story about who treated the patient and who supervised the work. If you are the nurse practitioner who saw the patient, the physician whose number appears on the bill, or the coder asked to use that number, you may know exactly where the story changes. The treatment record, the submitted claim and the supervision rule on that service date belong together. The billed physician’s name still has to connect to the work in Split/Shared Billing: Who Performed the Substantive Facility Visit? and Annual Wellness Visit Fraud: A Physician’s Name Cannot Do the Work.

Why the Physician’s NPI Matters

The physician’s national provider identifier can change how much Medicare allows for the service. Direct nurse practitioner and physician assistant claims generally use 85% of the physician fee-schedule allowance, while qualifying physician-supervised incident-to claims can use 100%. When a nonphysician practitioner supervises an incident-to service, the applicable nonphysician payment basis remains.

That difference gives the billing identity financial value. In the Sparrow settlement announcement, the Justice Department alleged that advanced practice provider services went through at the physician rate without satisfying the incident-to requirements. The alleged advantage came from how the practice attributed the work to a physician. The care could be real and the claim’s account of it still be false.

There is also a visibility problem. In its March 2026 report to Congress, the Medicare Payment Advisory Commission explained that incident-to billing makes it harder to count encounters by practitioner type and assess clinician quality. It reiterated its earlier recommendation that advanced practice registered nurses and physician assistants bill Medicare directly, eliminating incident-to billing for their services.

We see the same practical problem from the insider’s side. A payment record carrying a physician’s number can conceal the person whose work generated it. The person who knows the clinic’s daily workflow can supply what the billing identity leaves out.

What Constitutes Fraud When Billing Incident To?

It is incident-to billing fraud when a practice knowingly bills another clinician’s work under a physician’s number without the involvement or supervision Medicare requires. The Centers for Medicare & Medicaid Services describes the False Claims Act as reaching false claims a practice knows about, deliberately avoids knowing about or submits with reckless disregard for the truth. For an insider, the useful question is concrete: what did the practice tell Medicare, what actually happened, and who understood the difference?

The Medicare Benefit Policy Manual requires an initial personal service and continuing active involvement in the course of treatment. The later service must be integral to that treatment, with eligible personnel and the required supervision. The treatment plan connects the billed work to the practitioner’s actual management of the patient.

A physician’s signature is easy to find at the bottom of a chart. The initial service, ongoing involvement and supervision have to be found in the care itself. Employment and physician ownership likewise leave those questions unanswered. We look at who began the treatment, who carried it forward, who performed the billed work and who actually supervised it.

The personnel question reaches beyond the job title. State scope of practice, the covered service, enrollment, payer credentialing and supervision each have their own role. The NPI identifies a practitioner. It does not supply all the qualifications or conditions needed for payment. Orange Medical’s admissions below show how substituting a physician’s identity can conceal the work of an uncredentialed provider.

Office incident-to billing concerns qualifying noninstitutional services. Facility split/shared billing covers eligible visits involving a physician and a nonphysician practitioner, with its own rules for whose work supports the claim. When a practice bills in both settings, we compare the setting on the claim with where the patient received care.

What Are the CMS Incident-To-Billing Guidelines for 2026?

The CMS incident-to-billing guidelines for 2026 permit real-time audiovisual direct supervision for applicable services, excluding audio-only supervision and services with global-surgery indicators 010 or 090. The 2026 final-rule fact sheet describes the expanded permanent allowance. The other incident-to conditions remain, and only the supervising physician or other practitioner may bill for the incident-to service.

The supervision category matters too. Designated care-management services and qualifying behavioral-health services can use general supervision. For the office claim in front of us, we connect the service to its supervision category, the actual supervising practitioner and the evidence of that supervision.

How the Supervision Rule Changed

The December 31, 2019 regulation required the supervisor to be in the office suite and immediately available. For claims governed by that rule, a staff schedule or travel record can directly contradict the supervision represented by the bill.

The December 31, 2020 regulation allowed audiovisual virtual presence during a public health emergency when indicated to reduce exposure risk. The January 2024 version expressly extended the audiovisual allowance through the end of that year and excluded audio-only supervision.

For 2025, the agency made audiovisual direct supervision permanent for specified incident-to services with professional component/technical component indicator 5 and for code 99211. Its 2025 final-rule fact sheet also continued the temporary allowance for other affected services through that year.

We match the billed service and date to the required form of supervision, then compare that requirement with what the practice’s records and people can show. A later signature cannot move the supervisor backward through the calendar.

What the Incident-To Billing Cases Show

Pain Specialists Billed Under an Absent Owner’s Number

In its corporate guilty plea, Pain Specialists, P.A. admitted billing services under its physician owner’s NPI while he traveled, when personal consultation or direct supervision was required. The Justice Department’s March 2025 announcement places the criminal conduct between November 2015 and January 2020. The travel evidence goes directly to the participation or supervision the services required.

The practice separately agreed to a $240,000 civil False Claims Act settlement covering allegations over a longer period. That agreement addressed Medicare incident-to billing and Medicaid’s requirement to use the provider’s own number. For an insider, the useful comparison is the billed identity against the actual worker, the owner’s location and the payer’s requirement for that service.

Orange Medical Admitted Altering the Treatment Record

Orange Medical Care admitted that records falsely showed physician participation in services performed by uncredentialed providers. In the August 2024 settlement announcement, the Justice Department described admissions involving billing under physicians’ identities without the required rendering or supervision, and altered records identifying a physician as the treating clinician. The release identified travel abroad as evidence of missing involvement on many occasions.

The practice and its physician defendants agreed to a $600,000 settlement. The government joined a case brought by a private whistleblower, and the resolution distinguished Medicare incident-to conditions from New York Medicaid’s rendering-provider and enrollment requirements. The same substituted identity had to be examined against each payer’s rules.

We see the absurdity in making the chart agree with the bill by changing who supposedly treated the patient. The admitted alterations made the clinical record repeat the false billing story. That is why the schedule, travel evidence and people who actually worked the visit matter alongside the signed note.

Sparrow’s Complaint Described New Problems Under Doctors’ Names

Sparrow settled allegations that advanced practice provider services were billed as physicians’ incident-to services without meeting the required conditions. The Justice Department announced the resolution in July 2023. The whistleblower’s complaint gives a concrete account of what a review of the charts allegedly revealed:

A new complaint puts the connection to the physician’s initial service and treatment plan squarely in view. For the nurse practitioner or coder who recognizes that pattern, the crucial comparison is the work described in the encounter against the physician involvement represented by the claim.

What an Insider Can See Behind the Claim

The evidence joins the submitted claim to the people, work and supervision behind it. The claim supplies the payer, service date, billed service and practitioner identity. The treatment record supplies the clinical work and its connection to the plan. Staff schedules, travel records, credentialing information and supervision evidence can show whether the billing account fits what happened in the practice.

An article in the Journal of AHIMA, Busting Bad Medicine: a Call to Action Addressing Healthcare, Fraud, Waste, and Abuse, published in 2017, describes comparing treatment dates, treatment details and nurse or physician signatures. Its point extends beyond finding a signed entry:

That is where your knowledge of the office can matter. You may know who saw the patient, who was available to supervise, why a note changed or who directed the billing staff to select the physician’s number. We connect that account to the records and government payment. The comparison is strongest when the encounter, claim and decision inside the business can be followed together.

In a healthcare practice, the billing system may sit outside the treating clinician’s control. If your concern is the gap between your work and what the practice billed, we can assess that problem with you alongside the clinical and supervision evidence.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. Our work starts with the connection between the false claim, the government’s money and the people who knew how the practice was billing. That is the connection these cases make visible.

When You Know Who Actually Saw the Patient

If your practice puts a physician’s number on work you know tells a different story, speak with our whistleblower experts about the visits and claims. We work beside you to build the case around the treatment, supervision and billing decisions, and bring in Medicare billing fraud whistleblower lawyers who understand incident-to cases. Contact us to put what you know about the office behind your strongest incident-to whistleblower case.