The Future of Fee-for-Service Reimbursement by Allison Garrison
Billing & Coding Update by Martin Kubier
Tell me about shared billing. Does it apply to our clinic?
Shared billing is Medicare’s option for billing in a hospital or clinic setting. There is no “incident to” available to PAs in the hospital. Shared billing is a way to maximize billing for the PA-physician team. If coordination of care or counseling is involved and takes more than 50 percent of the time, this can be used to form the evaluation and management (E/M) level: 99212 is 10 minutes, 99213 is 15 minutes, 99214 is 20 minutes, and 99215 is 40 minutes. Then the claim is filed under the physician and paid at 100 percent of the fee schedule.
Rules for shared billing:
- The physician and the PA must be employed by the same practice.
- The PA cannot be employed by the hospital. The PA is used by the physician to see patients in the hospital.
- The PA and the physician must have a face-to-face visit with the patient on the same day.
- The physician must perform some part of the E/M history, exam, or medical decision making. What was done and by whom must be documented.
- The filing must show the PA and the physician acted separately. The physician can’t just review and sign off.
Many of my patients have complained that their prescriptions are not being paid when a PA signs. What’s happening?
Check script labels and see how they are written. If not correct, get busy and contact the pharmacist and get it changed. Make sure the pharmacy lists the physician as the prescriber. Most likely they list the PA as the prescriber, which most insurance companies do not recognize or pay for. Under Oklahoma law, PAs alone cannot write for medications. We are delegated this task by our delegating physician, and his name needs to be on the script to be legal. Most pharmacies use the physician name, then a slash with the PA name, as in Dr. Smith/PA Jones.
Why can PA services be billed under the physician’s name and not be fraud?
We are agents of the physician. We are delegated by the physician’s authority to work in the physician’s name as if the physician did the work. We provide physician services. We are non-physician providers. In that respect, to most insurance companies, we are invisible. However, each company is different. Some want to know if a PA provided the service, but they want us to bill under the physician’s name and Provider Identification Number (PIN). Some want the PA’s name to be in Box 31 of the 1500 form with the physician’s name in Box 33. This clearly identifies who provides the service and who bills.
While several companies instruct PAs to bill this way, their computer will still kick it out. Such claims will have to be refilled with an explanation or a paper claim filled out with a letter, explaining why it was done this way. Some companies now accept a claim with the PA in box 31 on odd days of the month, but the next month will except them on every third day… At least it seems that way. They say they don’t know why, but it happens that way.
Solution? Make it a routine to keep all Explanation of Benefits (EOB), refile all denials, and keep a record of the denials and explanations. Perhaps it’s better to contact each company separately and ask what they prefer. For example, CIGNA wants PAs to file under the physician’s name but requires no PA name in box 31. This is because they recognize that PAs are agents supervised by the physician.
In contrast, Nurse Practitioners are not agents. They work with physicians. CIGNA does not recognize NPs, and if NPs file under a physician, CIGNA will pay at present. Perhaps in the future, CIGNA may start looking at this as fraud. So if the insurance company wants the PA to file in a specific way, it is not fraud if PAs follow the instructions.
Here’s a quick summary: Rule #1: Private companies do it their way. PAs need to keep track of each company our patients use, and then if needed call and find out how they want PAs to bill. Rule #2: Private companies may change their mind. Someone may forget to tell the person at the claims desk how to handle PA billing. Again, keep track of EOBs, refile everything, and keep a record of denials. Perhaps someday we as a group can get the companies to establish a policy for PAs that will be consistent, fair and favorable.
Recently I was a patient in a large, multi-specialty clinic on the OU campus. I have been seeing the same specialist for the past ten years. Since my doctor has retired, my recent visit was with a new physician. When I received the bill, I was identified as a new patient. I recalled in one of your lectures, you said such treatment was not to be considered a new patient visit. I called the clinic and they assured me it was a correct billing since the doctor was new. What gives?
In order to be a new patient, you should have not been a patient in that practice for the past three years. Just because the physician is new does not make it a new patient visit. After looking at your bill, I see it shows you did see your previous physician six months earlier. So time is not a factor. I called the OU billing office. To my surprise, I ran into a wall of utter frustration. Most of the billers assured me they were correct. I even talked to two supervisors, and they concurred. I tried to explain the rules as I knew them: same tax ID number, same specialty, no new patient charge. In most multi-specialty clinics, they use the same tax ID number for all the doctors. If the patient sees another doctor from a different specialty, it will be a new patient. But this only applies to the same specialty.
Only after explaining a call will be made to the Oklahoma Insurance Commissioner did your clinic agree to adjust the charge. Now, why is this important? If one considers the number of patients seen at the clinic – and there are a large number of Medicare patients – an observant person could easily have caused a major financial problem. If an auditor came in and found even a few claims that were miss-coded, the clinic could be fined. Also, who-ever reports them is eligible for a reward. So I wonder how many billers charge a new patient visit when the patient sees the doctor, then the PA within the three year time period. Do they construe it as a new patient visit? I will be looking closer from now on.
Will you discuss billing for varied bed settings? The question: When can a PA be paid caring for patients that occupy beds in hospitals, acute care, swing, skilled nursing and custodial care? We offer physician services. It makes sense that we could step in for the doctor, see these patients, and bill for it.
Medicare has several rules when a PA substitutes for a physician seeing a patient in a specified bed. First, there’s hospital and acute care where a Pa may do the admitting orders and the H&P. Medicare does not allow PAs or other mid-level practitioners to admit to a hospital, but they can do the admission work, the H&P and the initial orders. As for private payers, I have no examples of Blue Cross, Health Choice, Aetna or others not paying for a PA’s work.
As for payment for treating a patient in a swing or skilled nursing bed? Medicare requirements for a swing bed stay are massive – over 170 pages long. Here are a few highlights: Medicare defines a swing bed as a hospital bed where the patient can rehabilitate and hopefully improve a medical condition. While swing bed is considered a skilled nursing bed, so the patient must need skilled nursing. The patient must be in the hospital for three days prior to a swing bed admission. It is considered a new admission, prompting a new H&P and new orders. The patient must meet strict criteria and be reevaluated often. In the case of a skilled bed, the patient must be able to have rehabilitation potential as in the swing bed, but in a separate facility.
Medicare requires the physician to make a decision to admit the patient assigned to a skilled or swing bed. The physician must have a face-to-face visit and do the initial H&P. The PA cannot do the H&P and have the physician co-sign. There is some disagreement among Medicare carriers whether the PA can write the initial orders and have the physician co-sign, but all agree that the physician must do the admitting H&P. Now if the patient is discharged from the skilled bed facility, sent home and then readmitted to the skilled bed facility, the PA is able to do the re-admit H&P and the orders.
In the skilled bed setting, the patient must be evaluated, something the PA also can do. In a nursing facility, if not an employee, the PA can perform the initial H&P. The patient needs to be evaluated each 60 day period. The physician and the PA are supposed to alternate visits. The PA can see the patient for acute medical conditions as many times as medically necessary.
We’re opening an after-hours clinic staffed by MDs and PAs. When a patient is seen in the after-hours clinic, can this be billed as incident-to or should it be billed as though only the PA saw the patient?
As insurance companies tighten up rules and Medicare decreases payments, no doubt we will see some creative ideas to maximize reimbursements. Incident-to is just one area where some may try to circumvent the correct way to bill. Beware: It’s a red-flag danger zone!
A quick review here: Under Medicare, incident-to billing occurs when the physician sees a patient on the initial visit and establishes a diagnosis and treatment plan. Incident-to occurs when the PA sees the patient on follow-up visits. There is a physician’s plan already in place that dictates treatment. No decision by the PA for treatment is made. However, no matter what it is called, when a PA sees a patient, it needs to be listed as though the PA saw the patient and did the work. Also, under incident-to, the physician must be in the same office suite as the patient when services are rendered. So if there is a main clinic and an after-hours clinic, for correct incident-to billing, the physician must be in the space designated as the after-hour clinic. The space should be identified in the cost report. If the physician is not in the after-hour clinic, then treatment cannot be billed as incident-to.
I hope that clarifies the issue. Something else that will raise red flags occurs when an acute care clinic is billing incident-to for what usually are acute problems, not chronic. New problems seen by a PA cannot be billed as incident-to. Remember: Hours of operation have nothing to do with incident-to billing.
In a new development, Blue Cross/Blue Shield now pays PAs at the same rate o reimbursement as Medicare: 85 percent of the physician’s rate. Why? So far my calls to BC/BS have not produced a credible answer. This question does raise the possibility that other insurance companies will also cut reimbursement to save money. Obviously this will have an impact on PAs.
I have been told by my office manager that a PA cannot bill a 99215 as “incident-to”. She says Medicare policy does not allow a PA to bill for this high an E/M service.
We’ve had this question before. For the sake of clarity, let’s repeat: Medicare does not have a policy that would prohibit a PA for billing “incident-to” even at the highest E/M level. Just be sure to document all the necessary data. Remember that the physician must see the patient first and develop a treatment plan. The plan must be followed and not varied, even in the PA’s judgment. And there must not be any treatment for a “new” problem. While it is not impossible to bill a level 99215, it seems questionable as to the medical necessity requiring a follow-up visit at that level. I have heard of a larger insurance company not allowing PAs to bill for anything more than a level 99213, but I fell this was because they did not understand what a PA could do.