Private health insurance companies present a different challenge for coverage of medical services provided by PAs but not because these insurers fail to cover PA-provided medical services. Most do. The problem is that there are a large number of insurance companies, HMOs, and PPOs in the market, and their policies may differ both in how medical services provided by PAs are covered and in how claim forms should be submitted. Even within the same insurance company, PA coverage policies can change based on the particular plan that an individual or group has selected, the specific type of service being provided, and the part of the country in which the service is delivered.
It is important to understand the role private insurance companies play in the claims and reimbursement process. Private insurance companies are in business, not unlike General Motors or IBM, to make a profit. In fact, one of the major goals of even nonprofit insurers, such as Blue Cross/Blue Shield, is to increase their cash reserves (the equivalent of profit to a nonprofit company).
An insurance company is required to live up to its legal, contractual obligations as stated in the policy document; that is, to provide an agreed-upon service for a given price (premium). Insurers are not necessarily in business to assure that everyone receives access to care. Nor are they in business to guarantee that all qualified health care providers are fairly and adequately compensated for their services. Health care providers often try to assign "moral obligations" to insurance companies, but they are not obligated to accept them. Although the hope is that insurance companies have a basic concern about the health needs of the general public and fair payments to practitioners, it should not be expected that this is their primary consideration.
Which health care professionals do insurance plans cover? Generally, insurance plans state that they cover medically necessary services provided by doctors of medicine and osteopathy. Some plans do not get overly specific in terms of listing each type of health care practitioner that may provide services under the plan. Physician assistants practice medicine with physician supervision. Medical services performed by a PA that are (1) within the scope of his or her training and expertise and (2) in accordance with state law are considered to be delegated acts of the supervising physician. This reinforces the concept of the PA as delivering "physician" services.
Most private insurance companies use this logic when dealing with claims for medical services provided by a PA if those services are billed under the physician's name. The majority of insurers require that the bill for medical services provided by PAs be filed under the physician's name and provider number, just as Medicare requires these same services to be filed under the "incident to" provision (with payment going to the PA's employer). A few private insurers want the claim to be filed under the PA's name. PAs should check with the individual insurance company (normally the claims department of the provider/professional relations department) for their particular policy on coverage for medical and surgical services provided by PAs. AAPA members may access the payer database for additional details on their state payers.
When contacting insurance companies to determine their policy on coverage for medical services provided by PAs, be sure to phrase your questions with terminology that the company understands. Do not ask someone in the insurance company's claims or provider relations department if PAs are reimbursed for services provided under the company's health plan. Because most companies don't directly reimburse PAs, the person on the phone may answer your question negatively. However, if you ask whether physician services performed by a PA are covered when the physician submits the bill, you will usually get a positive response. The two ways of asking that question may seem to be just a matter of semantics to you, but to an insurer there may be a fundamental difference. You should also ask for clarification regarding company policies on supervision, initial visits, and other practice issues. Here are some sample questions you should ask when trying to clarify a company's policies:
- Do you cover medical or surgical first assisting services provided by PAs when working under the supervision of a physician?
- Are PAs credentialed or enrolled?
- Are PAs issued provider numbers? If not, is it acceptable to submit bills under the supervising physician's provider number?
- Can the PA see the patient on the initial office visit?
- Are there any specific supervision requirements? Do you defer to state law?
- Do you defer to state law regarding the services PAs can provide?
- Is coverage also provided in a hospital setting?
It is important to be aware of all company policies and restrictions to ensure proper reimbursement. Also be cautious of revealing too much information about yourself or your practice when calling so that you do not target your practice for an audit.
Problems remain with some insurance companies, with some of the newer managed care entities, and when PAs first assist at surgery. Many of these companies do not have a clear understanding of the PA concept and the services PAs provide. These insurers must be educated. The responsibility for that task falls upon the AAPA national office, state chapters, and each PA. The Academy has educational materials that can be mailed or used during a face-to-face meeting with those in decision-making positions within the insurance company (i.e., medical directors and managers of the claims or provider relations department). If you send this information to an insurer, you should always follow up with a phone call offering to provide more specific details about how you provide care to your patients and to answer any additional questions they might have. Be sure to contact the AAPA's Third-Party Reimbursement office in the Government and Professional Affairs Department at 703/836-2272, ext. 3219 or 3218, for additional information.
Know the Rules
Coverage requirements and regulations affecting PAs (such as scope of practice and supervision requirements) can vary from program to program. Do not assume that the guidelines for Medicare also apply to Medicaid. The modifier code used for TRICARE/CHAMPUS may have a very different meaning to private insurance companies. In addition, regulations in the Medicare or Medicaid programs may be more restrictive than state law.
Contact the appropriate government agency or private insurance company to get specific information about the guidelines and requirements that apply to the medical services PAs provide. Many private insurance companies do not have written procedures concerning the coverage of PA services. However, most state and federal government programs do. It is always safer to have written (as opposed to verbal) information. Contact the appropriate Medicare, Medicaid, or Workers' Compensation offices (names, addresses, and phone numbers can be provided by the AAPA Reimbursement Office at extension 3219 or 3218).
The American Academy of Physician Assistants is actively working to eliminate the differences in regulations between the various state, federal, and private insurance programs. The AAPA believes that state law is the appropriate mechanism to regulate PA practice and that the myriad of different rules and reulgations imposed by private and government payers is confusing, unnecessary, and detrimental to the efficient delivery of health care services.
