Physician Assistant Reimbursement: Hot Topics

Physician Assistant Reimbursement: Hot Topics

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Physician Assistant reimbursement: Hot Topics James A. Kilmark, PA-C Physician Assistant in Emergency Medicine Emergency Physicians Medical Group: PA/NP Collaborative Team Co-Lead PA St. Joseph Mercy Hospital Emergency Department, Ann Arbor MI Past President Michigan Academy of Physician Assistants Michigan Academy of Physician Assistants Chairperson Reimbursement Committee Governor Appointed Member Michigan Board of Osteopathic Medicine and Surgery Disclaimer: This Presentation is provided for informational purposes only and does not constitute legal or payment advice. The ultimate responsibility for statutory and regulatory compliance, as well as the proper submission of claims, rests entirely upon the provider of services. 3

Learning Objectives Statistics Michigan PAs Review of Michigan Law regarding PA scope of practice Public Act 379 Blue Cross Blue Shield of Michigan and BCN August 2017 The Record credentialing / recredentialing MAPA Meeting with BCBSM / BCN officials Oct 2017 BCN Refusal of payment for PA services as a primary care provider? Refusal of payment for services provided by a Physician Assistant CMS Appeal process for denial of claims 4

Source: 2015 AAPA National Survey 5

Source: 2015 AAPA National Survey 6

Source: 2017 AAPA Salary Report Data collected Feb-March 2017 N=302 (Michigan) 7

Scope of Practice for PAs & Physician / PA relationship in practice The boundaries of a PAs scope of practice are determined by four parameters: 1. Historically - ***Delegation by a Supervising Physician (and the physicians scope of practice)***well..sort of ENTER Legislation Public Act 379 *** 2. PAs Education and Experience 3. State Law 4. Facility Policy 8

Michigan Public Health Code Practice as a Physician Assistant means the practice of medicine, osteopathic medicine and surgery, and podiatric medicine and surgery and is defined as a health profession subfield (MCL 333.17001, 333.17008). "Practice of medicine" means the diagnosis, treatment, prevention, cure, or relieving of a human disease, ailment, defect, complaint, or other physical or mental condition, by attendance, advice, device, diagnostic test, or other means, or offering, undertaking, attempting to do, or holding oneself out as able to do, any of these acts (MCL333.17001). 9

PA Scope of Practice Historically PAs practice medicine in MI under legislation that defined Physicians in a supervisory role. The MI Public Health code also used terms related to Physicians delegating abilities to the PA Public Act 379 Enacted March 22 nd 2017 PAs now practice medicine as part of a practice agreement within a healthcare team PAs also have full prescribing rights including schedule 2-5 controlled substances without restriction as long as it is authorized within a defined practice agreement. 10

Public Act 379 Summary PAs will work within a Practice Agreement with a participating physician PAs will continue to practice medicine and remain a sub-field of Medicine, Osteopathic Medicine and Podiatry boards PAs will continue to be held to the standards of competency and training The terms supervision and delegation were removed in law in favor of a practice agreement with a physician Removes arbitrary PA/physician ratios in the statute PAs are now fully independent prescribers MUST HAVE A DEA # AND MICHIGAN CONTROLLED SUBSTANCE LICENSE PAs will continue to practice with a participating physician as a member of a practice team 11

Public Act 379 Summary What is a participating physician a physician designated by a group of physicians under section 333.17049 to represent that group, or a physician designated by a health facility or agency under section 333.20174 to represent that health facility or agency. 12

Public Act 379 Summary What is a Practice Agreement? A Practice Agreement is a written agreement between a PA and a participating physician. It generally defines the communication and decision making process by which the PA and the participating physician provide medical care to their patients. It may also place conditions on specific duties, procedures or drugs, if the parties of the agreement choose to do so. It is not intended to be a burdensome or lengthy document, but rather, provide a general understanding of each professional s knowledge and skills utilized in each unique practice setting. 13

Public Act 379 Summary What is required in a practice agreement? a. A process between the physician assistant and participating physician for communication, availability and decision making when providing medical treatment to a patient. The process must utilize the knowledge and skills of the physician assistant and participating physician based on their education, training and experience. b. A protocol for designating an alternative physician for consultation in situations in which the participating physician is not available for consultation. c. The signature of the physician assistant and the participating physician. d. A termination provision that allows the physician assistant or participating physician to terminate the practice agreement by providing written notice at least 30 days before the date of termination. Go to www.michiganpa.org for a sample practice agreement and to learn more about PA practice in MI 14

Does the state of Michigan and the Public act define what PAs Can t do: PAs cannot perform refraction/optometry PAs cannot perform abortions or prescribe medications or a device that will lead to miscarriage or fetal death PAs CAN pronounce death but Cannot sign a death certificate PAs performing flex sig / colonoscopy in and outpatient facility **does not pertain to hospital based settings**michigan Rule 325.3802 specifies that endoscopic procedures performed in a surgical outpatient facility are defined as "surgery" and can only be performed by a "physician." 15

Blue Cross Blue Shield of Michigan and Blue Care Network: What s new? MAPA recently met with officials

Blue Cross Blue Shield Of Michigan Register with BCBSM and obtain an individual PA PIN or add a PA to a group. Call BCBSM s Provider Enrollment and Data Management department at 800-822-2761 bcbsm.com/provider/enrollment* http://www.bcbsm.com/providers/join-the-blues-network/enrollment.html

Blue Cross Blue Shield Of Michigan a quick refresher Allows Direct or Indirect Billing for services provided by a PA **This is not CMS incident to or shared service ** Direct Billing refers to the billing of services under the provider identification number of the PA practitioner who performed the service Source: BCBSM The Record April 2008

Blue Cross Blue Shield Of Michigan Direct Billing: If the PA provides any level of service that is provided without fulfilling one of the three indirect billing scenarios the bill is submitted using the PAs license number and 85% of the Physician s Fee schedule will be paid to the practice. Bill services performed by the physician assistant by reporting the billing physician's or group's PIN in field 33b and the physician assistant's license number in field 24J on the CMS-1500. Source: BCBSM The Record April 2008 - page 21

Blue Cross Blue Shield Of Michigan Indirect Billing describes billing for services rendered by the PA under the PIN of the supervising physician Source: BCBSM The Record April 2008 - page 21

Blue Cross Blue Shield Of Michigan Indirect Criteria Any service where the physician delivers any component of the service Services for which the physician has provided specific clinical direction to the Non physician Practitioner prior to or during the service Services for which the PA has presented pertinent clinical findings and obtained approval of evaluation and management by the physician prior to the end of the day following the service Source: BCBSM The Record April 2008 - page 21

Blue Cross Blue Shield Of Michigan Report the PIN of the billing physician in field 24J, Rendering Provider ID #, on the CMS-1500 claim. Do not include the physician assistant's license number on these claims. Source: BCBSM The Record April 2008 - page 21

BCBSM Update on Reimbursement for Hospital Employed PAs BCBSM has indicated that a hospital will not be reimbursed for services provided by hospital employed PAs if the PAs salary is part of the negotiated hospital payments. THE QUESTION! ARE HOSPITALS INCLUDING PAS IN THE FINANCIAL REPORTS SUPPLIED TO BCBSM IN THE PAYMENT NEGOTIATIONS?

BCBSM and BCN announce requirement for enrollment / re-enrollment for PAs August 2017 The Record Physician assistants must re-enroll to be reimbursed for services within their scope of license for dates of service on or after Feb. 1, 2018. Beginning Oct. 1, 2017, physician assistants must: Re-enroll and be credentialed with Blue Cross Blue Shield of Michigan and Blue Care Network, including our Medicare Advantage programs. Complete our attestation form, indicating that they have a legally required practice agreement with a physician, along with other required documents. For participation with BCN, PAs must enroll as part of an existing contracted group or request participation via a new group practice. Complete a CAQH ProView credentialing application within 14 calendar days of submitting enrollment requests. Current reimbursement arrangements will be terminated for dates of service after Jan. 31, 2018 BCBSM The Record August 2017 http://www.bcbsm.com/newsletter/therecord/2017/record_0817/the_record_0817.html

BCBSM and BCN announce requirement for enrollment / re-enrollment for PAs Regarding dates of service on or after Feb. 1: PAs who have re-enrolled by Jan. 31 will be eligible for reimbursement for services within their scope of license either directly or under a group for all lines of business. PAs who have not will have their claims denied. PAs may choose to continue to be affiliated with physician groups and bill under the groups. If so, PAs should ensure they indicate the groups information when they contract and re-enroll. PAs will continue to be reimbursed at 85 percent of the physician fee schedule. Current BCN authorization and referral requirements will continue to apply. Why are Blue Cross and BCN making this change? We re making this change because the state of Michigan allows PAs to work within their full scope of practice without direct or general supervision by a participating physician. The state also requires that PAs initiate and maintain a practice agreement with participating physicians. How to contract and re-enroll Starting Oct. 1, PAs can find and use the Blue Cross and BCN practitioner agreements and enrollment forms on bcbsm.com. We ll also provide additional information in upcoming editions of The Record and BCN Provider News. If you have questions, contact Provider Inquiry or your provider consultant. http://www.bcbsm.com/newsletter/therecord/2017/record_0817/the_record_0817.html

BCBSM and BCN meeting with MAPA Oct. 17, 2017 Discussion of intent for re-enrollment / enrollment under BCN Discussion of indirect v direct billing parameters for BCBSM and how it compares to incident to and shared service under CMS Discussed PQRS and how to communicate with BC on those who are already enrolled Discussed Tiered incentives like physicians under Physician Group Incentive Payments (PGIP) Discussed reimbursement for psychiatric services

BCBSM and BCN meeting with MAPA Oct. 17, 2017 Discussed direct payment of services provided to PA Considering direct payment in 2018 for certain plans Credentialing of PAs include BCBSM, BCN, BCNA, MAPPO, they will not require credentialing for PPO.yet?

BCN and payment for primary care services MAPA has received inquiries from practices that they are receiving rejection for payment of PA services Cited cause is that PAs cannot be designated as primary care providers Suspicion is that practices are not submitting claims under the collaborating physician Request claims rejections be passed along to MAPA who will intern communicate with officials at BCN

Private Payers Private payers cover services delivered by PAs/NPs Individual payers may require billing for NPPs to be submitted under the physician s name and/or provider number or the hospital s tax ID Not necessarily the same as Medicare s incident to policy

Private Payers It is not fraud to bill under the physician/hospital if authorized by the payer It is a mistake to assume that all payers follow the same billing rules Must have specific policies from payers in your region

Medicare Payment Covered Services Coverage is limited to the services a PA is legally authorized to perform in accordance with State law (or State regulatory mechanism provided by State law). Generally the services of a PA may be covered under Medicare Part B, if all of the following requirements are met: They are the type that are considered physician s services if furnished by a doctor of medicine or osteopathy (MD/DO); They are performed by a person who meets all the PA qualifications, They are performed under the general supervision of an MD/DO; The PA is legally authorized to perform the services in the state in which they are performed; and They are not otherwise precluded from coverage because of one of the statutory exclusions. Excerpt from Medicare Policy Manual: Chapter 15 190 32

Recent CMS/WPS refusal of payment Group practices have had refusals for payment when PAs within different specialties perform services on the same patient on the same day CMS Taxonomy for PAs.only 1 = 97 What to do? Recently MAPA was made aware of WPS refusing payment for procedures performed by PAs Radiology setting percutaneous renal biopsy Trauma setting bedside bronchoscopy in trauma patient PLEASE FORWARD SIMILAR REFUSALS TO MAPA

Recent CMS/WPS refusal of payment for procedures MAPA / AAPA encourage these cases be appealed through the defined CMS 5 level appeal process. 1 st level appeal does not address scope of practice 2 nd level appeal should include explanation of inclusion of scope of practice 3 rd level of appeal by an Administrative law judge should include State law scope of practice (inclusive or without exclusion) Evidence of education and training of the service Hospital privledging for providing the service

Questions? 35

Medicare Medicare will reimburse for services provided to Medicare beneficiaries provided by PAs in all areas / settings: At 85% of the physician fee schedule Why is this important? 36

Medicare Incident to Incident to is a Medicare billing provision that allows PAs to bill Medicare under the physician s NPI number, if Medicare s strict criteria for incidentto billing are met: Services are provided in a physician s office or physician s clinic; Physician sees Medicare patient on initial visit, establishes a diagnosis and treatment plan. PA sees patient on follow up visit; For established Medicare patients with a new problem, the physician sees the patient first for the new problem, establishes a diagnosis and treatment plan, PA sees patient on follow up visit; a Physician is on site, within the suite of offices, when the patient is seen by the PA; Services are within the PA s state law scope of practice; and the PA represents a direct financial expense to the physician billing (W-2 or leased employee, or independent contractor). 37

Medicare Incident to The physician must continue to see the patient at a frequency that reflects ongoing management of the patient s care. If all of the above criteria (previous slide) are met, you may bill Medicare under the physician s NPI with reimbursement at 100%. If any of the first 4 bulleted criteria are not met, bill Medicare under the PA s NPI with reimbursement at 85%. 38

Medicare Incident to PAs may see new Medicare patients, see established Medicare patients with new problems, and may see Medicare patients under state law guidelines for supervision; the claim must then be submitted under the PA s NPI. Reimbursement at will be at 85% of the Physician Fee Schedule. 39

Medicare Incident to Remember! Incident to is a Medicare Provision this provision DOES NOT necessarily apply to Private Payers Incident to applies to the outpatient physician office only! There are separate provisions for hospital based PA practice. Should your office use incident to? 40

Medicare Shared Service Shared Visit billing is a Medicare provision that applies to an evaluation and management (E/M) service in which both the physician and the PA participate, allowing the combined service to be billed under the physician s NPI, with reimbursement at 100% of the Physician Fee Schedule. The shared visit concept does not apply to procedures or critical care services or nursing home visits. The PA and physician must be employed by the same entity. Shared visits can be applied to initial and subsequent hospital visits, as well as visits in the Emergency Dept. The patient must be seen by the PA and the physician on the same calendar day. However, this does not mean at the same time. 41

Medicare Shared Service Shared Services apply to Hospital Inpatient / Hospital Outpatient and Emergency Department Settings. Incident to does not apply in these settings 42

Medicare Shared Service To properly document a Shared Service the Physician must have a face to face encounter with the patient on the same calendar day as the PA The Physician must document a portion of the evaluation and management (E&M) encounter. Seen and Agree, I agree with the PAs plan does not meet the level for shared service billing. 43

Medicare Shared Visit Key Points Hospital inpt/outpt or ED Services performed on same calendar day Common employment E/M services, but not critical care or procedures Physician delivers face-to-face portion of E/M service Clear documentation on medical record of physician s professional service