November 17, 2023
PAs Can Establish and Review Patient Plan of Care
November 28, 2018
By AAPA Reimbursement Department
Q. What is hospice care?
A. Hospice is medical and nursing care focused on supporting the comfort and quality of life of patients who are terminally-ill .
Q. What’s the current Medicare policy regarding PAs and hospice services?
A. Until recently, Medicare policy was fairly restrictive with regard to PAs (physician assistants) and hospice care. PAs were not permitted to provide care that was directly related to a hospice patient’s terminal illness. Similar health professionals, physicians and nurse practitioners (NPs), are currently able to provide and be reimbursed, for these services.
Q. What’s changing on January 1, 2019 regarding Medicare’s hospice policy?
A. The Bipartisan Budget Act of 2018 and subsequent accompanying regulations, as a result of advocacy work of the AAPA, have expanded care options for hospice patients by broadening the Medicare definition of hospice “attending physician” to include PAs. Starting January 1, 2019, PAs, like physicians and NPs, will be permitted to provide, manage, and have such hospice services reimbursed by Medicare. This will enable PAs in this capacity to establish and review a hospice patient’s plan of care.
Q. Why is this important to patients?
A. Patients who receive a diagnosis of terminal illness should be able to focus on working with healthcare professionals to manage their disease, deal with pain control, concentrate on the quality of their life and other end-of-life matters without having to face unnecessary barriers to accessing hospice care. The omission of PAs from providing care to this patient population threatened to exacerbate patient access difficulties and weaken continuity of care. The Bipartisan Budget Act of 2018 took an important step in addressing these concerns. The intent of adding PAs to the term “attending physician” was to expand the number of providers to care for the hospice population. This will also ensure greater continuity of care so that patients that have PAs as their primary provider of care can continue to have the health professional who knows them best participate in their care provision.
Q. Do there remain any limitations on PAs providing hospice care?
A. There are some aspects of hospice care that PAs are still not permitted to provide. For example, only a physician or medical director may certify terminal illness, only a medical director may admit a patient to a hospice, and PAs cannot take the position of a physician as one of the required members of an interdisciplinary group (hospice physician, registered nurse, social worker, and pastoral or other counselor). These restrictions apply to NPs as well.
There remains one service that can be provided by both physicians and NPs, but not PAs: a face-to-face encounter prior to recertification for hospice care. Prior to initial certification, a physician or medical director is required to certify terminal illness. Only physicians are able to perform that task under Medicare. This qualifies a patient for a 90-day hospice period. After 90 days, a medical director must recertify terminal illness. After 180 days have passed, prior to recertification by the medical director again (for 60-day periods from this point forward), a face-to-face encounter must occur. NPs, while not permitted to recertify terminal illness, are permitted to conduct the face-to-face encounter to determine continued eligibility. PAs are not given the ability to conduct this face-to-face encounter. AAPA is working with CMS and Congress to find a solution to the face-to-face encounter exclusion.
Finally, restrictive language regarding hospice established before CMS’ policy change may still exist in state laws and regulations. Any PA interested in providing care as a hospice attending physician should confirm that their state laws and regulations do not prevent PAs from acting in this capacity. For questions regarding restrictive hospice language in your state, contact Erika Miller at [email protected].
For more information, contact AAPA’s Reimbursement Department at [email protected].