Your source for the most up-to-date information on Medicare rules,
Medicaid regulations and managed care issues affecting PAs.
13 July 2009
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Medicare Scam Alert
The Centers for Medicare & Medicaid Services (CMS), which administers the Medicare program, is warning health care professionals and practice personnel that perpetrators are sending faxes to physician offices posing as staff from the local Medicare carrier or Medicare Administrative Contractor (MAC). The fax instructs physician staff to respond to a questionnaire to provide private account information updates within 48 hours in order to prevent an interruption in Medicare payments. The fax may have the official CMS logo and/or the contractor logo to enhance the appearance of authenticity.
Medicare FFS health care professionals, including physicians and PAs, should be wary of this type of request. If you receive any request for information in the manner described above, please check with your carrier or contractor before submitting any information. Medicare providers should only send information to a Medicare contractor using the address found in the download section of the CMS.gov Web site.
Arkansas BCBS Continues Its Negative Interpretation
In 2007 PAs in Arkansas were successful in having legislation passed that required private payers in the state to reimburse for services delivered by PAs. The mandate requires that Blue Cross Blue Shield of Arkansas (BCBSAR): (1) cover PAs at the full rate, and (2) maintain supervision requirements that are no more restrictive than existing state law.
An initial meeting in 2007 that included AAPA reimbursement staff, leaders from the Arkansas PA chapter, and officials from one of the largest payers in the state, BCBSAR, appeared to smooth the way for implementation of the reimbursement mandate.
However, over the past few months BCBSAR has been asking that PAs enroll with the payer and agree to a payment that is 85 percent of the physician fee schedule. This is the rate currently being paid to NPs
When PA leaders and AAPA reimbursement staff inquired about adherence to the reimbursement mandate (payment at the full rate) a BCBSAR official said that their interpretation of the mandate required payment at the full non-physician rate. The actual statute didn't use physician or non-physician in its language. It simply said at the full rate.
In December 2008, AAPA and Sheryl Cash, PA-C, then-president of the Arkansas PA Academy, wrote a detailed letter to BCBSAR, the Arkansas State Insurance Commissioner, and to the member of the state legislature who sponsored the bill to voice our strong belief that BCBSAR is ignoring both the letter and the spirit of the law. The then-state legislator (he left the legislature at the end of last year), responded with a letter stating that his intent was that payment be made for services provided by PAs at the physician rate. BCBSAR's legal department reviewed the matter and decided that their interpretation for payment at the full non-physician rate was in keeping with the language found in the law.
Arkansas Academy leaders and AAPA reimbursement staff will hold a conference call this week to decide on next steps in this ongoing dispute.
Hawaii BCBS Takes Another Step in the Right Direction
Hawaii Blue Cross Blue Shield, more commonly known as Hawaii Medical Service Association (HMSA), presumably understanding the problems with access to care within the Hawaiian Islands, became one of the few payers in the country that increased reimbursement for PAs from 85 to 90 percent about a year ago.
More recently, HMSA took another positive step that bodes well for an underserved practice on the Big Island run by Dan Domizio, PA-C. Working with a supervising physician, Dan is the only full-time health care professional at Puna Community Medical Center (PCMC). PCMC had been reimbursed at 90 percent of the physician rate for treating an underserved patient population group. During numerous conversations with the HMSA provider representative, Dan continued to ask why a community health center (CHC) "just up the road" that treated similar patients received 100 percent reimbursement while his clinic was limited to 90 percent reimbursement. After all, PCMC delivered the same high quality care as compared to the CHC.
HMSA eventually agreed to pay for medical services delivered by a PA at PCMC at the full physician rate. The policy change became effective on July 1. HMSA continues to pay at 90 percent for services delivered by PAs in non-underserved areas of the state. No word yet on whether other PA-led clinics in underserved communities will be treated similarly.
Medicare Releases the Proposed 2010 Physician Fee Schedule
On July 1, the Centers for Medicare and Medicaid Services (CMS) made available a display copy of the 2010 Medicare Physician Fee Schedule Proposed Rule (MPFS). AAPA Reimbursement Department staff is reviewing the proposed rule and, in consultation with members of the Government Affairs and Reimbursement Committee and AAPA leadership, will make comments on behalf of PAs as necessary.
Some of the highlights (or lowlights, depending on your perspective) of the proposal include:
- A proposed 21.5% decrease in the 2010 physician fee schedule.*
- Lower payments to help reduce the growing number of high cost imaging services.
- Remove the cost of physician-administered drugs.
- An update of practice expenses for health care professionals which should
provide a more realistic look at the costs involved in maintaining a practice. - Ending payments for consultation codes with the savings being distributed to existing evaluation and management services.
- Increasing payments for the Welcome to Medicare Exam.
Reimbursement Watch is a bi-monthly newsletter written by Michael Powe, AAPA Vice President of Health Systems and Reimbursement Policy. You are more than welcome to reprint items, just credit American Academy of Physician Assistant's Reimbursement Watch. Your comments, questions, and suggestions are welcome. Phone 703-836-2272 ext. 3211, Fax 703-684-1924 or Write: AAPA 950 North Washington Street, Alexandria, VA 22314-1552. E-mail address: This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
