If you've worked in behavioral health for any length of time, you've probably heard some version of these questions: Can my therapist bill under the psychiatrist? Is this considered incident to? Can we use a supervision model with this payer? They sound like straightforward questions, but they're actually missing the most important piece of information. Before we talk about incident to, supervision, or billing under another provider, we have to know who is paying the claim.

That's where I see organizations get into trouble. Someone attends a webinar, reads a social media post, or hears what another practice is doing, and suddenly that answer becomes "the rule." The reality is there isn't one rule. Medicare has its own incident to provisions. State Medicaid programs often have their own supervision requirements. Commercial insurance companies may have policies that differ from both, and sometimes the answer isn't found in a regulation at all but in the participation agreement you signed with the payer. Until you know which rulebook you're using, you really can't answer the question.

One of the biggest sources of confusion is that incident to and supervision are often used interchangeably. They aren't the same thing. Incident to is a Medicare billing provision with specific requirements. Supervision is a much broader concept that may be defined by Medicare, your state Medicaid program, a commercial payer, or even your contract with that payer. Sometimes those concepts overlap, but many times they don't, and assuming they do is where compliance issues begin.

A Real-World Example

Let's use an example. Imagine a behavioral health organization that employs a psychiatrist and an LSW. Leadership asks, "Can the LSW bill under the psychiatrist?" It sounds like a straightforward question, but it's impossible to answer without first asking, "Who is the payer?"

If the patient has Medicare, the conversation begins by determining whether the individual LSW independently qualifies to enroll as a Medicare Mental Health Counselor. While many LSWs do not meet Medicare's qualifications for independent enrollment, some do based on their education and supervised clinical experience. If independent enrollment is not an option, the analysis shifts to whether a Medicare incident to billing model is available and whether all of its requirements are met.

If the patient has Ohio Medicaid, the conversation changes. Ohio Medicaid recognizes LSWs as practitioners who may bill covered services directly when all applicable Medicaid requirements are met. Now you're analyzing Ohio Medicaid's supervision requirements and the applicable Ohio Administrative Code, not Medicare's incident to provision.

If the patient has commercial insurance, neither Medicare nor Ohio Medicaid necessarily provides the answer. Some commercial payers credential LSWs directly, while others do not. Some address supervision protocol under an independently licensed professional within their provider participation agreements or billing policies. Before deciding how the service should be billed, you have to understand what that specific payer allows.

The providers haven't changed. The service hasn't changed. Even the question hasn't changed. The only thing that changed was the payer, yet the billing analysis may be completely different. That's why I rarely answer the question right away. Instead, I ask another one. "Who is the payer?"

Even within Medicare, the analysis doesn't stop with "Is this incident to?" Different provider types have different authorities under their Medicare benefit categories. Clinical psychologists have “incident to” authority under Medicare, while clinical social workers, marriage and family therapists, and mental health counselors do not have incident to authority under their own professional services. That distinction surprises many organizations because independent enrollment in Medicare does not automatically mean every provider type has the same billing options.

Then there are exceptions. Federally Qualified Health Centers (FQHCs) operate under a different Medicare payment methodology with their own supervision provisions. Those rules are important if you practice in an FQHC, but they shouldn't automatically be carried over to physician offices or community behavioral health practices. The same caution applies when organizations try to apply Medicare concepts to Ohio Medicaid or assume one commercial payer follows another. Each time I hear someone say, "We were told this is how supervision works," my response is usually, "According to which payer?"

The 60 Second Decision Tree

When I'm asked an incident to or supervision question, this is the mental checklist I work through before I ever answer.