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presentation

Understanding Physician Assistants Reimbursement Environment

March 09, 2012



“Amidst all these overriding Medicare or health insurance guidelines surrounding the reimbursement for their assistants’ services, physicians would invariably feel exhausted for doubling up as medical billers along with their primary focus of clinical efficiency. Therefore, physicians would be well-off outsourcing medical billing services that are adept at handling their assistants’ reimbursement issue along with their own.”

From what used to be auxiliary to physicians’ main clinical services, services of physician assistants (comprising PAs, NPs, and Clinical Nurse Specialists) have evolved to be substitute to physician services themselves. In fact, in most of the primary care centers and non-surgical clinics, physician assistants’ have become as trustworthy as qualified physicians. Recognizing this phenomenon, majority of the primary care and non-surgical clinics are gradually migrating to an operational model dominated by physician assistants operating under one or two supervising physicians.

Although an alarming shortage of qualified physicians in the face of spiraling patient-population may have been the primary reason behind this changing equation, cost optimization or revenue augmentation (as physician assistants’ services can be bought at a comparatively lesser remuneration than what it can cost for physicians’ services) may also have equally been responsible for the shift towards physician assistants. The clinical or hospital management, on their part, would have happily carried on with this model as long as it seemed feasible but for the nuances of billing for their assistants’ services, which seem as challenging as billing for their own services.

The numerous guidelines that govern reimbursement for physician assistant services have tended to weigh rather heavy on physician practices. Amongst many such guidelines, the following are noteworthy:

  • Medicare requires the services provided by physician assistants (PAs) be reimbursed at 85 percent of the physician fee schedule unless specific billing exceptions such as ‘incident to” and “shared visits billing” apply. Further, PAs need to bill Medicare at the full physician rate, and be necessarily carrying a National Provider Identifier (NPI) number to alert the carrier to implement the 15 percent discount.
  • NPIs need to be updated with name changes and changes in employer. PAs must enroll with any new employer.
  • Services provided by PAs are reimbursable by Medicare when provided in offices or clinics, nursing facilities, hospitals, and ambulatory surgical centers.
  • Only services falling under the “Incident to Physician Services” are reimbursable at 100%. Otherwise, Medicare or insurance carriers are obliged to honor only 85% of the bill.
  • Medicare maintains a list of approximately 1,900 Current Procedure Terminology (CPT) codes for which a first assistant at surgery will not be reimbursed. For these codes, Medicare determined that a first assistant is not needed and will not pay for the services of any medical professional acting as a first assistant
  • Medicare restricts coverage of physicians, PAs, NPs, and Clinical Nurse Specialists for first assisting at surgery only. There are no restrictions for other services PAs provide in teaching hospitals.

Amidst all these overriding Medicare or health insurance guidelines surrounding the reimbursement for their assistants’ services, physicians would invariably feel exhausted for doubling up as medical billers along with their primary focus of clinical efficiency.  Therefore, physicians would be well-off outsourcing medical billing services that are adept at handling their assistants’ reimbursement issue along with their own. Medicalbillersandcoders.com – whose credibility and competence for providing comprehensive medical billing services, comprising Patient Scheduling and Reminders, Patient enrollment, Insurance Enrollment, Insurance verification, Insurance Authorizations, Coding and audits, Billing and Reconciling of Accounts, Account Analysis and Denial Management, AR Management, and Financial Management Reporting ranks amongst the best in the industry – may well be the preferential recourse to physician practices seeking the right answers to billing their assistants’ services.

For more information: Medical Billing Companies

 

Category : Revenue Cycle Management