MA Reimbursement Policies

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MA Medicare Reimbursement Brief: Click here to view

MA Medicaid Reimbursement Brief: Click here to view

MA Private Payer Reimbursement Brief: Click here to view

MA Workers Compensation Brief: Click here to view

Medicare Policy Chart for Physician Assistants

SETTING	SUPERVISION REQUIREMENT	REIMBURSEMENT RATE	SERVICES
Office/Clinic when physician is not on site	State Law	85% of physician’s fee schedule	All services PA is legally authorized to provide that would have been covered if provided personally by a physician
Office/Clinic when physician is on site	Physician must be in the suite of offices	100% of physician’s fee schedule ¹	Same As Above
Home visit/ House Call	State Law	85% of physician’s fee schedule	Same As Above
Skilled Nursing Facility & Nursing Facility	State Law	85% of physician’s fee schedule	Same As Above
Hospital	State Law	85% of physician’s fee schedule	Same As Above
First assisting at surgery in all settings	State Law	85% of physician’s first assist fee schedule²	Same As Above
Federally Certified Rural Health Clinics	State Law	Cost-based reimbursement	Same As Above
HMO³	State Law	Reimbursement is on capitation basis	All services contracted for as part of an HMO contract

¹Using carrier guidelines for "incident to" services.
²i.e. 85% x 16% = 13.6% of surgeon’s fee.

Aetna Updates 2010

Please find attached an excerpt from Aetna’s March, 2010 OfficeLink newsletter. The newsletter announces a change in policy regarding payment for services provided by PAs. Aetna will decrease its payment for service provided by PAs, NPs, and nurse midwives to 85% of the physician contracted rate effective June 1, 2010. As part of this policy change, Aetna is asking that PAs be officially listed in their network provider directories. The newsletter may be found in its entirety here: Office Link newsletter. Scroll to your state, select the March 2010 edition, and go to page 4 for the relevant information.

AAPA recommends the following:

For additional details, practices / facilities should contact their Aetna provider representative for the billing implications of this change in policy.
Note that there are strict legal prohibitions against state or national chapters and associations negotiating payment amounts with private third party payers. Review the Anti-Trust Implications of Negotiating with Third-Party Payers. Individual practices are able to negotiate payment levels with third party payers.
As always, practice contracts with payers should include specific language that says that PAs are covered for services consistent with state law guidelines for supervision and scope of practice.

Preliminary information from Aetna indicates that the payer is allowing services to be billed using a billing concept similar to Medicare’s “incident to” billing provision. Therefore, if “incident to” guidelines are met, PAs may bill office services under the physician’s name with reimbursement at 100% following implementation of the new policy in June, 2010. AAPA is seeking written verification of this policy as well as the following:

the potential applicability of Medicare’s “split/shared” billing provision;
implications for credentialing/enrollment;
placement of the NPI on claim forms; and
the ability of PAs to enroll as primary care providers.

Please check AAPA’s private payer postings for policy updates as they become available.

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