AAPA Comments on Critical Medicare Payment Proposals

Proposed 2022 Physician Fee Schedule Authorizes Direct Payment to PAs

September 17, 2021

By Michael Powe

A pending proposal from the Centers for Medicare & Medicaid Services (CMS) authorizing direct payment to PAs has positioned the profession to achieve a significant policy victory this year. In the proposed 2022 Physician Fee Schedule (PFS) rule CMS, the federal agency which administers the Medicare and Medicaid programs, announced plans to formally change Medicare regulations and give PAs the ability to directly receive payment when treating Medicare patients.

Currently, claims for PA-provided services can be submitted to Medicare under the PA’s name, but payment can only be made to the PA’s employer. Lack of access to direct payment potentially denies PAs both employment and practice flexibility in today’s rapidly changing healthcare environment. This policy change will put PAs on a level playing field with physicians and advanced practice nurses (APRNs) who already have access to direct Medicare payment.

Each year the Medicare program publishes a proposed PFS rule outlining the policy and payment changes the agency recommends making for the upcoming calendar year. The proposed rule, which is often more than a thousand pages in length, covers a vast array of health policy and coverage issues.

AAPA’s Reimbursement staff analyzes the rule to determine which issues are relevant to PAs and the patients they serve. The proposed rule is typically released in July and interested stakeholders – individuals and health organizations – have 60 days to offer their comments. AAPA submitted comments to CMS on September 13. CMS will review all comments received and publish its policy determinations in the final PFS on or before November 1. Policy decisions typically go into effect on January 1, 2022. Highlights of some of the priority issues are detailed below.

Hospice care and employment status
In the proposed rule CMS recommended authorizing PAs, physicians and APRNs who work in certified Rural Health Clinics (RHCs) and federally-qualified health centers (FQHCs) to act as “attending physicians” and provide certain hospice services to Medicare beneficiaries. PAs already have the ability under Medicare to be “attending physicians” when not employed by or working under contract for RHCs and FQHCs. AAPA fully supported this suggested policy change as it will improve access to essential services at a very vulnerable time in a patient’s life. We also requested that the agency remove other hospice program restrictions that prohibit PAs from providing the full range of care to beneficiaries who elect Medicare’s hospice benefit such as being authorized to: 1) order medication for hospice patients when employed by a hospice organization, 2) perform all required face-to-face visits and 3) certify terminal illness.

Split or shared billing
The agency recommended extensive changes to the provisions of split/shared visit billing in hospitals and hospital outpatient settings. AAPA comments were generally geared toward encouraging the reduction of unnecessary administrative burdens on health professionals and ensuring transparency and attribution of services delivered by PAs. For split/shared visit billing, we were supportive of capturing and billing the service under the name of the health professional who provided the majority of professional work when both a PA and a physician delivered care to the same patient on the same day. However, we did not support CMS’ desire to make all hospital evaluation and management services (e.g., admission history and physical, subsequent hospital visits) time-based for documentation purposes as is done with billing for critical care services. We asked the agency to defer such substantial changes in coding and documentation policy to a work group consisting primarily of health professionals.

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Direct supervision
During the COVID-19 Public Health Emergency (PHE), CMS allowed for many Medicare program flexibilities to free health professionals to extend care under dire clinical circumstances. One flexibility authorized direct supervision, which typically means on-site presence, to be accomplished through audio/visual communication methods. AAPA supported this provision in order to ensure an “all hands on deck” environment for delivering care during the PHE. In the proposed rule CMS asked if this flexibility should be continued after the PHE ends. Our comments stated that the flexibility should continue to apply to those health professionals who can be directly supervised by PAs, physicians and APRNs, but do not have the ability to bill Medicare on their own (e.g., RNs, LPNs and medical assistants), but not for PAs.

PAs are autonomous health professionals who have their own Medicare billing status. When PAs deliver care to Medicare beneficiaries and the service is submitted under the PA’s name there is no requirement for direct physician involvement. When PA-delivered care in the private office or clinic is billed under the “incident to” provision Medicare requires direct (on-site) physician supervision. This billing mechanism allows a service provided by a PA to be billed under the name of the physician. “Incident to” billing can be confusing, is often an inefficient way for PA-physician teams to deliver care, and hides the professional work contributed by PAs. For these reasons we do not support the ability of Medicare direct supervision for PAs via audio/visual technology.

Increased specificity of data to address disparities and inequities
AAPA also supported CMS’ goals of addressing disparities and promoting equity in healthcare. We agree with the agency’s desire for increased specificity of data to address disparities and inequities as a logical first step. AAPA also pointed CMS’ attention to two sources of health disparities caused by policies that: 1) restrict patient access to needed services, and 2) inadvertently allow for the inefficient provision of care. It is our belief that policies which better enable PAs to practice to the full extent of their education and competencies will increase access to care and contribute to a more equitable delivery of care to patients. This is especially true in rural communities where patients are typically older, sicker and experience more logistical challenges in obtaining care. The agency must continue to review and eliminate outdated and inefficient rules and regulations that do not recognize and promote the full utilization of PAs.

In addition to submitting formal comments, AAPA’s reimbursement and federal affairs staff continue to meet with and engage CMS officials in discussions about the essential role the PA profession has in improving the delivery of healthcare services to all patients.

Michael Powe is AAPA’s vice president of reimbursement and professional advocacy. For more information regarding reimbursement issues, contact AAPA’s reimbursement team at [email protected]. 

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