Getting Paid for Mid-level Services - …

1 Getting paid for Mid-level ServicesYOUR PRACTICE AND Mid-level Mid-level Services are covered by both public andprivate third-party payers, but reimbursement ratesmay s important to confirm payment schedules with allpayers to avoid for visits to Mid-level practitioners are sometimesreimbursed at a lower rate than physician incident to visit is billed at the same rate as aphysician value of adding Mid-level practitioners to yourpractice will likely increase given new models of reimbursement such as FastFACTSC hapter FastFACTSW hether Mid-level practitioners will pay for themselvesor even make money for your practice depends notonly on how productive they are, but also on how yourpayers reimburse for Mid-level Services . Because reimbursementpolicies vary among payers and sometimes include differingbilling requirements for PAs and NPs, it s difficult to 's vital to check each payer's policy individually. The conse-quences can be dire if you do it wrong, Ms.

2 Rathfon says. Thelast thing a practice wants is to spark an audit because of failureto master the details for billing a new service. Ms. Capko notes that you should check on reimbursementpolicies before making a salary offer to a Mid-level practitionerDocumenting telephone calls while on the go is a Snapwith MEMO-Snap OnCall Pocket Data Pads!Capture and Codeall-new CPT 2011 Telephone ServicesMEMO-SnapTM and MEMO-SnapTMMessage Mates are produced by Brandofino Communications, the publisher of Doctor s quick and inexpensive way to ensure accurate medical records andfollow-up for telephone, online, and after-hours patient consultations. Keep MEMO-SnapTMwith you for telephone notes while on call or on the go. The pad s vinyl cover has a pocket for storing completed forms. Capture and document telephoneencounters for completion of thepatient medical record. Check boxes to alert supportstaff to patient follow-up, newmedications, transcription,coding/billing.

3 Visit tips on using MEMO-Snap and for up-to-date informa-tion on coding and reimbursement fortelephone Memo & Coding Managementto make sure the numbers will work for your practice. (See What to Ask Your Payers. ) An accountant who specializes inhealthcare can help you navigate the often-complex analysis, shesays. This process works best if you ve already thought about thevolume of patients you expect the new Mid-level practitioner tosee each week, what types of patients he or she will see mostoften, and to what extent you or another physician in your prac-tice will need to be on the premises to supervise. All Mid-level Services will be covered by both public and pri-vate third-party payers, says Michael Powe, the AAPA s vicepresident of reimbursement and professional advocacy. Thequestion is whether those Services are reimbursed at the samelevel as physician-provided Services , or at a discount. Mr. Poweestimates that about 40% of payers offer discounted reimburse-ment for Mid-level Services .

4 Payers may have differing require-ments; for example, one may require specific circumstancesunder which the physician needs to review and sign off on themid-level practitioner s documentation, while another does not. Incident to ServicesMedicare and many other payers draw a distinction betweenservices that are billed by a Mid-level practitioner working inde-pendently and those billed incident to a physician visit. Inde-pendent visits that is, those made to a Mid-level practitionerbut not to a physician are reimbursed at a lower rate, often85% of the normal rate for a physician visit. Incident to visitsare billed at the same rate as a physician visit. If a physician ison the premises when the Mid-level practitioner sees the patient,and is available for consulting, the physician may not actuallyhave to see the patient for the visit to be billed incident to, although the physician may need to document the visit and thetreatment plan, rather than having the Mid-level practitioner doso.

5 (See Medicare s Reimbursement for Mid-level Services formore details on how Medicare defines incident to. ) Aetna, for example, changed its policy last year to conform toMedicare s, and now pays Mid-level practitioner visits at 85% ofthe contracted physician rates for covered professional practice will need to list the Mid-level practitioner s name inthe servicing provider field when you submit claims for servicesYOUR PRACTICE AND Mid-level by a Mid-level practitioner. You may also bill mid-levelservices on an incident-to basis at 100% of the physician rate. Not all payers allow incident-to billing. For example, BlueCross/Blue Shield of Rhode Island requires all Mid-level practi-tioners to bill under their own provider number, and pays thema percentage of the physician s rate as specified in its contractwith the physician. Ask each of your payers about its incident-to rules when you ask how to bill for Mid-level cases where the payer will grant 100% of your usual reim-bursement for Mid-level Services billed as incident to, wouldGETTING paid FOR Mid-level AAPA suggests asking these questions of each of your payers to findout their specific policies on reimbursement for PA Services .

6 (These con-siderations generally apply to NPs as well, although in some settings pay-ers reimburse NPs directly.) Do you cover medical or surgical first-assisting Services provided byPAs when working under the supervision of a physician? Are PAs credentialed or enrolled? Are PAs issued provider numbers? If not, is it acceptable to submitbills under the supervising physician's provider number? Can the PA see the patient on the initial office visit? Are there any specific supervision requirements? Do you defer tostate law? Do you defer to state law regarding the Services PAs can provide? Is coverage also provided in a hospital setting?It may be unwise to ask someone in the insurance company's claims orprovider relations department if PAs are reimbursed for Services providedunder the company's health plan. Because most companies don't directlyreimburse PAs, the person on the phone may answer your question nega-tively. However, if you ask whether physician Services performed by a PAare covered when the physician submits the bill, you will usually get a pos-itive response.

7 Also ask for clarification regarding company policies onsupervision, initial visits, and other practice issues. Source: AAPA, to Ask Your Payersyou ever want to bill that payer any other way? There are rea-sons you might, consultants say. When my clients were firsthiring Mid-level [practitioners], they all billed incident to, says consultant Mr. Hunt. Then they saw they could be moreeffective if they got them credentialed with their own [nationalprovider identification] numbers. Here s why. Even though practices were taking a 15% hit (orsometimes more, depending on payer and contract) on each visit,YOUR PRACTICE AND Mid-level you must check with each of your payers about specifics for han-dling credentialing and billing for Mid-level providers, many payers arelikely to follow Medicare s broad outlines. Here s a partial list:For both PAs and NPs: Services or supplies must be medically reasonable and necessary. Services are the type considered physician s Services if furnished byan MD or a DO.

8 Services are not otherwise precluded due to a statutory exclusion. The NP or PA is legally authorized and qualified to furnish the servicesin the state where they are performed. Incident-to Services and supplies may be covered under the followingcircumstances: Must be an integral part of the patient s normal course of treatmentduring which the physician has personally performed an initial serviceand remains actively involved in the course of treatment; Are commonly furnished without charge ( , included in the physi-cian s bill); Are an expense to the physician; Are commonly furnished in the physician s office or clinic; and Must occur when the physician provides direct supervision he orshe is present in the office suite and immediately available if NPs only: Services are performed in collaboration with a physician. An NP may be selected as a hospice beneficiary s attending physician,but he or she cannot certify or recertify a terminal illness with a prog-nosis of six months or s Reimbursement for Mid-level ServicesMr.

9 Hunt says they found it simpler not to have to worry aboutwhether a physician was physically present in the office for allthe Mid-level practitioner s appointments. They also had moreflexibility about where to use Mid-level Services : For example,some sent their Mid-level practitioners to conduct hospitalrounds, checking on patients and their treatments. Many payers,including Medicare, don t allow incident-to billing of Mid-level Services for new patients or new treatment plans, but onlyGETTING paid FOR Mid-level An NP may bill the Medicare program either directly for Services ,using his or her NPI, or under an employer s or contractor s NPI. Claims for incident-to Services must be submitted under the supervising physician s NPI and identified on provider file by specialty code 50. Services are paid at 85% of Medicare s physician fee PAs only: Services are performed by an individual who meets all of the PA qualifications.

10 Services are performed under the general supervision of an MD or DO. The physician supervisor or designee need not be physically presentwhen a service is being furnished unless state law or regulationsrequire otherwise. The PA s employer or contractor must bill under the PA s NPI or may bill under a physician s NPI if the physician in the group prac-tice/employer has performed a visit that assesses the patient andestablishes a plan of care. Claims for incident-to Services must be submitted under the super-vising physician s NPI. The PA must be identified on provider file by specialty code 97. Payment may be made only to the PA s employer or contractor. Services are paid at 80% of the lesser of these: the actual charge or85% of the physician fee schedule : Medicare Information for Advanced Practice Nurses and Physician Assistants, publishedSeptember 2010 by Centers for Medicare and Medicaid seeing established patients with previously diagnosed prob-lems.