• title-reimbursement
  • Medical and surgical services delivered by PAs are covered by Medicare, Medicaid, TRICARE and nearly all private payers. It is important to verify each payer’s coverage policies for PAs. Each payer has its own guidelines regarding service coverage and payment.

     

     Third-Party Reimbursement: Issue Brief [PDF]

    This issue brief gives an overview of PA reimbursement through third-party payers.

     

    Antitrust Implications of Negotiating with Third-Party Payers [PDF]

    Learn about antitrust laws related to payment for services.

    Resources
    Medicare pays for medical and surgical services provided by PAs at 85 percent of the physician fee schedule. This rate applies to all practice settings, including hospitals (inpatient, outpatient and emergency departments), nursing facilities, homes, offices and clinics. It also applies to first assisting at surgery. Medicare had a myriad of policies and regulations that must be followed in order to avoid allegations of fraud and abuse.

    The following articles detail policy for billing for services provided by PAs. Member login is required. Access these documents.

    2013 DME Face-to-Face Requirements : IMPLEMENTATION DELAYED
    The Centers for Medicare & Medicaid Services (CMS) has delayed implementation of the new rule, originally scheduled for July 1, 2013, which requires documentation of a face-to-face encounter for a patient receiving certain types of durable medical equipment (DME). The new implementation date is anticipated to be “sometime” in 2014, at which time the supplier will require a copy of the face-to-face documentation to be signed by a physician in order to deliver/dispense the applicable item(s).

    Pre-op H+P
    The pre-op H+P is generally not a billable encounter as it is considered part of the “global package”. 

    Medicare: Qualifications and Coverage for Services Provided by PAs
    This document contains the citation from the Medicare Manual describing the qualifications required for PAs, the services that are covered when provided by PAs, and the physician supervision requirements for PAs under the Medicare program.

    Medicare Preventive Services 
    PAs may provide Medicare Preventive Services, including the "Welcome to Medicare" exam and the “Annual Wellness Visit.” There are many rules, requirements, limitations and screening schedules for these services.

     Medicare "Incident-to" Billing  
    "Incident-to" is a Medicare provision that allows for services provided by a PA in the office to be billed under the NPI of the physician with reimbursement at 100%. Strict criteria must be met.

    Medicare Shared Visit Billing  
    Shared visit billing is a Medicare provision that allows for services provided in the hospital by both the PA and the physician to be billed under the NPI of the physician with reimbursement at 100%.

    Medicare and PECOS Enrollment  
    Physician assistants must apply first for an NPI number, then enroll in Medicare via the PECOS system. This document contains detailed instructions.

    Third-Party Payer Policy for PAs
    Practices must ascertain the payment policy and claims submission instructions for services provided by PAs from each payer with whom they contract.

    First Assisting at Surgery 
    This document includes billing rules for first assisting, the Medicare exclusion list and Teaching Facility Rules.

    Home Health Services 
    There are new home health requirements for a face-to-face visit, which may be provided by a PA.

    Medicare Skilled Nursing/Nursing Facility/Inpatient Rehab Facility Billing
    Physicians managing patient care in nursing facilities, skilled nursing facilities, and inpatient rehab units may delegate visits to PAs.

    Medicare Preventive Services 
    PAs may provide the "Welcome to Medicare" visit, annual wellness visit, and other preventive services.

    Supervision of Diagnostic Tests - Medicare
    The billing rules for diagnostic tests require that Medicare providers meet a specified level of physician supervision to bill for certain diagnostic tests. 

    Medicare E-Prescribing Incentive Program
    PAs are eligible for the Medicare e-prescribing incentive payments, but are also subject to the penalties if not successfully prescribing.

    CMS Electronic Health Record Incentive Program 
    PAs are not eligible for the Medicare EHR incentive program. PAs in limited circumstances can be eligible for the Medicaid EHR incentive program.

    Calculating PA Productivity 
    This collection of information highlights the considerations and challenges associated with calculating PA Productivity.

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