July 30, 2021
Accurate Representation of Who Provides Care Benefits Patients
By Trevor Simon, MPP
April 7, 2020
A substantial percentage of medical services delivered by PAs to Medicare, Medicaid, and commercial payer beneficiaries may be “hidden” in the health care system. Due to certain payer billing provisions and/or the fact that some payers do not enroll/credential PAs, many PA-provided medical services are billed under the name of the physician with whom the PA works. When this occurs, it is difficult, if not impossible, to appropriately measure the volume of services or the quality of care delivered by PAs. This article will explore some of the obstacles to transparency of PA services, why transparency is important, and what AAPA is doing to improve transparency.
Billing mechanisms that affect transparency
“Incident to” is a Medicare billing provision that allows services provided by PAs in an office or clinic to be reimbursed at 100% of the physician fee schedule, as opposed to the typical 8 %. This is achieved by attributing services provided by PAs to the physicians with whom they work after a series of Medicare-specified conditions are met.
Medicaid programs authorize PAs to treat Medicaid patients in all 50 states and Washington, D.C., and PAs are expected to enroll as, at minimum, “ordering and referring providers.” In forty-four states and Washington, D.C., PAs are enrolled as “rendering providers,” which permits PAs to include their names and National Provider Identifiers (NPIs) on claim forms in a section that identifies who provided the service. However, in six states, these services are instead attributed to the collaborating physician.
Some commercial payers do not enroll/credential PAs or acknowledge them as recognized providers of care. While services provided by PAs are often still reimbursed by such insurers, the expectation is to attribute services to the collaborating physician, as opposed to including the PA’s name and NPI on a claim form to indicate they rendered the service. Policies of enrollment/credentialing may vary within a company depending on whether the line of business is commercial, Medicaid managed care, Medicare Advantage, or behavioral health.
Some hospitals have contractual arrangements with insurance companies that specify that professional services provided by PAs are not separately reimbursed, but rather included in an increased facility fee paid to the hospital. When this occurs, there is no guarantee the amount paid to the hospital is in line with the number and type of services provided by PAs.
Electronic Health Record (EHR) systems often can be designed and customized to meet the needs of those who use them. Systems that are not optimally designed may make it difficult to attribute work performed by more than one provider during the same service. When there are multiple authors or contributors to a document, all signatures should be retained so that each individual’s contribution is unambiguously identified. If the EHR does not have functionality to enable multiple providers to document and sign, and retain each professional’s contribution, it may be impossible to verify the work performed by each provider. Review EHR Toolkit here.
Provider directories are listings maintained by public and commercial payers that alert beneficiaries to the healthcare professionals within their insurance network. While not always the case, PAs are occasionally omitted from a payer’s provider directory. When PAs are included, they are often listed under a group titled “physician assistant” instead of the specialty in which they practice, making them unable or difficult to be found by patients. The exclusion of PAs, or limitation in how PAs are represented, occurs in provider directories across public programs (such as in Physician Compare under Medicare, as well as in Medicaid directories) and commercial payers.
Who is harmed by the lack transparency of PA services?
The healthcare stakeholders that are negatively affected by the lack of transparency of PA services are numerous and include patients, payers, employers, and PAs themselves. Accurate representation of who provided what care would benefit patients by simplifying care coordination between health professionals, increasing the efficiency of care by decreasing burdensome reporting requirements for billing mechanisms like “incident to,” enhancing informed decision making by providing accurate information on care options through provider directories, and reducing confusion from summaries of care that don’t identify the health professional the patient has seen.
Payers would benefit from accurate data that allows for analysis of workforce, network adequacy, and provider value, and permits greater clarity on resource allocation and contracting decisions. Employers would benefit from precise data on who provided what services when determining the level of contribution of respective health professionals to the practice. Finally, PAs themselves benefit from unbiased data as it would ensure their contribution to the health system and their employer is not masked, they would not be hidden as a care option under opaque provider directories, and it may aide in their ability to participate in reimbursement programs that set a minimum participation threshold, such as Medicare’s Quality Payment Program.
As a result of the fact that such a broad group of health care stakeholders is negatively affected, AAPA has found similarly broad willingness to address these various transparency issues. While progress continues to be made, transparency obstacles persist for a number of reasons, including that some of the affected stakeholders may not be aware of the extent to which a lack of transparency harms them, insufficient understanding of the levels at which PAs practice, misunderstandings regarding what is required to enhance transparency, a false belief that greater transparency will lead to duplication of services, logistical hurdles, and competing priorities.
To promote transparency, accuracy, and accountability, AAPA’s advocacy efforts focus on ensuring that all payers enroll/credential PAs, list PAs in provider directories, and have policies requiring that claims be submitted under the name of the health professional who performed the service. AAPA works with other affected stakeholders to positively influence Medicare, Medicaid, commercial and hospital policy to be more transparent regarding PA services.
Trevor Simon, MPP, is director, regulatory policy at AAPA. Contact him at [email protected].