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Medicare Policy Chart for Physician Assistants

SETTING

SUPERVISION
REQUIREMENT

REIMBURSEMENT RATE

SERVICES

Office/Clinic when physician is not on site

State Law

85% of physician’s fee schedule

All services PA is legally authorized to provide that would have been covered if provided personally by a physician

Office/Clinic when physician is on site

Physician must be in the suite of offices

100% of physician’s fee schedule 1

Same As Above

Home visit/
House Call

State Law

85% of physician’s fee schedule

Same As Above

Skilled Nursing Facility & Nursing Facility

State Law

85% of physician’s fee schedule

Same As Above

Hospital

State Law

85% of physician’s fee schedule

Same As Above

First assisting at surgery in all settings

State Law

85% of physician’s first assist fee schedule2

Same As Above

Federally Certified Rural Health Clinics

State Law

Cost-based reimbursement

Same As Above

HMO3

State Law

Reimbursement is on capitation basis

All services contracted for as part of an HMO contract

1 Using carrier guidelines for "incident to" services.
2 i.e. 85% x 16% = 13.6% of surgeon’s fee.

Aetna Updates 2010

Please find attached an excerpt from Aetna’s March, 2010 OfficeLink  newsletter.  The newsletter announces a change in policy regarding payment for services provided by PAs. Aetna will decrease its payment for service provided by PAs, NPs, and nurse midwives to 85% of the physician contracted rate effective June 1, 2010. As part of this policy change, Aetna is asking that PAs be officially listed in their network provider directories.  The newsletter may be found in its entirety here: Office Link newsletter. Scroll to your state, select the March 2010 edition, and go to page 4 for the relevant information.

AAPA recommends the following:

  • For additional details, practices / facilities should contact their Aetna provider representative for the billing implications of this change in policy.
  • Note that there are strict legal prohibitions against state or national chapters and associations negotiating payment amounts with private third party payers. Review the Anti-Trust Implications of Negotiating with Third-Party Payers. Individual practices are able to negotiate payment levels with third party payers.
  • As always, practice contracts with payers should include specific language that says that PAs are covered for services consistent with state law guidelines for supervision and scope of practice.

Preliminary information from Aetna indicates that the payer is allowing services to be billed using a billing concept similar to Medicare’s “incident to” billing provision.  Therefore, if “incident to” guidelines are met, PAs may bill office services under the physician’s name with reimbursement at 100% following implementation of the new policy in June, 2010. AAPA is seeking written verification of this policy as well as the following:

  • the potential applicability of Medicare’s “split/shared” billing provision;
  • implications for credentialing/enrollment;
  • placement of the NPI on claim forms; and
  • the ability of PAs to enroll as primary care providers.

Please check AAPA’s private payer postings for policy updates as they become available.

 

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