Physician Assistants, Payers, and Your Practice

Independent studies and articles in peer-reviewed journals have reached consensus about the ability of physician assistants (PAs) to deliver high-quality care to patients in all practice settings. Extending patient access to cost-effective medical and surgical services as part of the physician-PA team is a basic tenant of the PA profession.

Physicians should also understand that nearly all public (Medicare and Medicaid) and private payers reimburse medically necessary services delivered by PAs, if that same service is covered when provided by a physician. The overarching theme is that PAs provide services that are considered physician’s services if furnished by a doctor of medicine or osteopathy. The range of services that PAs are authorized to deliver is determined by state law.

Payer rules can differ and it’s essential to not assume a “one-size-fits-all approach.” While Medicare is a significant payer for many practices, the reimbursement rules do not necessarily determine the payment policies of other third-party payers. Determine the major payers in your practice and obtain, in writing, their coverage policies for PAs. Many payers have written policies regarding PAs on their website as part of a coverage policy manual. If you have difficulty acquiring the information from payers the AAPA can provide assistance. It’s also a good idea to have specific language that recognizes PAs as part of the practice’s contract with private payers.

Fortunately, there are only a couple of variations of the theme. The service is either billed under the name and provider number of the PA, or under the name and number of the physician. Despite how the PA’s services are billed, payment is made to the employer of the PA. Billing for hospital-employed PAs can take on some added complexities depending on the hospital’s negotiated contract with various private payers.

Here are some important points about billing for services delivered by PAs:

• PAs should have a National Provider Identification (NPI) number and in most cases can be enrolled in Medicare using the same 855i enrollment form used by physicians.

• Medicare covers services provided by PAs in all settings at 85 percent of the physician fee schedule when the PA is billing under their own name and NPI number.

• When billing Medicare under the PA’s name and number, general supervision meets Medicare’s guidelines. General supervision is typically defined as the availability of electronic communication (such as a cell phone) between the PA and the supervising physician.

• Medicare allows PAs to provide care in the office and bill the service under the name of the supervising physician, if Medicare’s more restrictive rules governing “incident to” billing are observed.

• Most private payers do not follow Medicare’s rules for billing. Aetna is one example of a private payer that does emulate Medicare’s payment policies for PAs.

• Always bill Medicare and other payers with the same Current Procedural Terminology (CPT) code used by physician for the same service. Both CPT and Medicare policy allow PAs full use of all CPT codes as allowed by state law.

• Bill payers at the full physician rate. Use of the PA’s NPI number or a modifier code will alert payers to appropriately discount the reimbursement rate, if necessary.

• All 50 states and the District of Columbia cover PAs under their fee-for-service or managed care plans. Some states do not cover PAs when they first assist at surgery.

PAs can significantly augment the revenue stream of reimbursement to the practice. They also provide services that while not separately billable by the physician or the PA -such as responding to patient telephone calls and performing global post-surgery visits) are a necessary part of providing high quality care to patients. The key is to assure correct billing procedures to maximize reimbursement while avoiding fraud and abuse concerns.

Michael Powe is the vice president for reimbursement and professional advocacy with the American Academy of Physician Assistants (AAPA).This blog was provided in partnership with the American Academy of Physician Assistants. For more information, visit www.aapa.org.