Denials

How to Handle Claim Denials from Private Insurers

Before deciding that you have been unfairly treated by a third-party payer, make sure that you ascertain the reason given for the denial. Most private insurance companies and government payers will send a written reason for the denial, often known as the Explanation of Benefits (EOB). First, check the EOB or the denial notice to eliminate the possibility of a simple error, such as an incorrect CPT code, a missing provider signature, or other clerical error that caused the denial. The EOB should specifically indicate if the denial was because a physician assistant provided the service (often stated as “service only covered when provided by an MD/DO” or “Physician assistants not considered authorized providers under the plan”).

The two most common reasons a first-assisting-at-surgery claim is denied are: use of the incorrect modifier and use of an assistant on a restricted code. While Medicare uniformly uses the AS modifier for first assisting at surgery, private insurances determine which modifier they use, typically either AS, 80, 81, or 82. Do not assume that all companies use the same modifier. Like Medicare, most insurance companies have a specific list of surgical codes for which a first assistant at surgery is not covered.

When you receive a denial, contact the insurance company and verify that the correct modifier was used. Also verify that the surgical procedure billed allows for a first assistant. If the insurance company does not have a surgical list and utilizes “medical necessity” as coverage criteria, then you must back up your decision to use the assistant. First, check the Medicare list (Appendix M). Coverage by Medicare can lend support that use of an assistant is medically necessary. Next, contact the American College of Surgeons (ACS). The ACS, along with 15 other surgical subspecialty organizations, publishes a report that, in their opinion, suggests when a surgical procedure requires a physician as an assistant at surgery. While this study references the need of a physician as an assistant at surgery, it can be generalized to address the overall need for a first assistant, including a PA. The latest survey was published in 2007, using all the surgery codes in the AMA’s 2007 CPT manual. You may also wish to include any medical research references that would support your appeal.

Ready to Fight, but with Whom?

Before you develop a plan of action, find out who has the ability to reverse the claim denial. If the insurance plan was purchased by an individual, you may safely assume that the insurance company alone made the decision about whether your services were covered. However, do not make that same assumption for a patient who has group health insurance coverage through an employer. In this case, receiving an EOB or letter of denial from an insurance company (even if it is on the insurance company’s letterhead) does not necessarily mean that the insurance company is the ultimate decision maker in this situation. The insurance company might simply be the third-party administrator of the health insurance plan and another entity — the company for whom the patient works — may actually make decisions concerning the practitioners covered under the health plan. Make sure that your efforts are directed at the decision maker and not the “messenger.”

Self-insured Health Plans

Most large and many medium-sized businesses are choosing to self-insure their employee group health insurance plans. When a business self-insures, it assumes the financial risk of paying the health costs of covered employees. These self-insured businesses may contract with traditional insurance companies to handle the plan’s administration, paperwork, and claims processing. In this situation, the insurance company becomes the third-party administrator (TPA) or provides administrative services only (ASO). The decision as to which medical practitioners will be considered covered providers under the plan is made by the business, which often receives guidance and actuarial input from the insurance company. A call to the insurance company whose name is on the EOB/denial letter can elicit whether the health plan is one of the following:

An indemnity-type plan, in which covered provider decisions are made by the insurance company, or
A self-insured plan, in which the patient’s employer controls who will be considered a covered or authorized provider.

Businesses tend to self-insure for at least two reasons.

First, they can save money by eliminating the following:

The insurer’s profit margin required to keep a reserve pool of money used to pay claims;
The insurer’s cost for actuarial duties related to calculating premiums; and
The tax imposed by certain states on health insurance premiums.

Second, the legal and regulatory burdens are reduced when a business self-insures its employee health plan. Instead of being regulated by the insurance requirements in each state where the business has employees, self-insured plans fall under the jurisdiction of the federal Employee Retirement Income Security Act of 1974 (ERISA), which typically has compliance requirements that are much less demanding than state requirements.

If the plan is self-insured, deal with the health benefits department of the business that employs your patient. Explain the situation to the patient and ask if he or she would be willing to help resolve the matter. Tell the patient that you have provided quality medical care and it is only fair that your services be covered. Most of your patients will be willing to help. A letter written by both the practice and the patient to his or her health benefits office will often be sufficient to reverse the denial.

In a situation where the patient’s health plan is not self-insured and the insurance company makes the final decision on covered practitioners, you will need to direct your concerns to what motivates insurers to change their coverage policies. Expressing righteous indignation may make you feel better, but it normally does little to change the insurance company’s decision. Keep in mind what is important to insurance companies: (1) retaining quality business or subscribers as customers; (2) maintaining or increasing their market share; and (3) maintaining a positive corporate image. Channeling your efforts toward these issues will give you a better chance of attaining success, which is payment for your services.

What should you do if a claim is denied? First, do not forget about it, and do not consider it to be uncollectible. That is the best of all possible worlds for the insurance company or the self-insured business because their subscribers will get quality medical care at no cost. It is important for you and your practice to contest any and all unfair denials. But that alone may not be enough. Your response needs to be multifaceted. Again, it is important to enlist the support of the patient and/or the business that pays the premium to the insurer. Their unhappiness or dissatisfaction has a direct impact on each of the three areas mentioned above that are of greatest concern to the insurer.

When you get a denial, contact the AAPA’s Third-Party Reimbursement Office in the Government and Professional Affairs Department at 703/836-2272. The Academy attempts to keep a record of insurance companies that do not cover medical services provided by PAs. The following section contains sample letters and reference materials that can be sent to businesses or insurance companies from the AAPA in response to a denial. A sample of a letter that your patient should send to the self-insured business or insurance company is also included. Please note that one reference piece addresses physician assistants in all practice settings, while the other is specific for PAs in surgery. Of course, you and your supervising physician(s) should write letters of protest to the self-insured business or insurance company whenever coverage for PA-provided services has been denied.

SAMPLE LETTER SENT BY THE AAPA TO THE INSURANCE COMPANY FOR DENIAL OF CLAIM FOR MEDICAL SERVICES

[Date]

[Department Manager]
[Official Title]
[Insurance Company Name]
[Address]
[City, State & Zip]

Dear [Name of Claims Department Manager]:

We are contacting you in reference to a claim denial in which [name of insurance company] refused to pay for medical services provided by [name of PA]. [Name of PA] is a [use either certified, licensed, registered, or a combination, if applicable] physician assistant (PA) who is fully qualified by education, training, and the [name of the appropriate PA state regulatory agency] to provide medical services in the state of [name of state].

There may be no explicit language in [name of patient] policy covering medical services provided by a PA. However, it is important to understand that a physician assistant provides the same medical services that would otherwise be provided by a physician.

The cost of providing medical care does not increase (and may, in fact, be less) when provided by a PA. Additionally, by state law, PAs always practice with physician supervision. Numerous government and other objective studies have shown that the quality of care to patients remains high when medical care is provided by a physician assistant. A study performed by the US Congressional Office of Technology Assessment stated, “Within the limits of their expertise, PAs provide care that is equivalent in quality to care provided by physicians.” We would be happy to provide you with copies of these reports.

Perhaps there is a lack of familiarity with physician assistants. For your information, I have enclosed a summary of the PA profession. This summary deals with a physician assistant’s education, training, and certification process. As you can see, services provided by PAs are covered by Medicare, CHAMPUS/TRICARE, and most Medicaid programs and private insurance companies.

Policyholder satisfaction is also an issue. The patient is placed in a difficult position. The patient does not understand why [his/her] health insurance policy will not cover medically necessary services provided by a competent, state-authorized health care practitioner. If [name of insurance company] doesn't cover the fee for this medically necessary service the financial burden may fall upon the patient.

The American Academy of Physician Assistants (AAPA) is the national professional association of the physician assistant profession. The AAPA represents more than 70,000 practicing PAs throughout the country. The use of PAs is growing rapidly within all segments of the medical community. There is no logical reason to deny this claim based on the quality of care, cost, or patient satisfaction.

We would appreciate having your comments on this matter at your earliest convenience.

Sincerely,

Michael L. Powe, Vice President
Health Systems and Reimbursement Policy

PHYSICIAN ASSISTANTS

Physician assistants (PAs) practice medicine with supervision by licensed physicians, providing patients with services ranging from primary medicine to very specialized surgical care. A physician assistant’s scope of practice is determined by state law, the supervising physician’s delegation of responsibilities, the PA’s education and experience, and the specialty and setting in which the PA works.

Physician Assistant Education

PAs are educated in accredited programs located at schools of medicine or allied health, universities and teaching hospitals. Prerequisites for admission generally include two years of relevant college course work, plus patient care experience. PA education is an average of 26 months in length. The typical student has a bachelor’s degree and nearly 4 years of health care related experience before entering a PA program.

The first phase of the program consists of intensive classroom and laboratory study, providing students with an in-depth understanding of the medical sciences. Subjects include anatomy, pharmacology, physiology, clinical laboratory medicine and microbiology, pathophysiology, physical diagnosis, medical ethics and behavioral sciences. The second phase consists of clinical rotations with physician preceptors in a variety of settings, such as hospitals, long term care facilities, and physicians’ offices. Most programs require clinical rotations in internal medicine, family medicine, surgery, pediatrics, obstetrics/gynecology, psychiatry, emergency medicine and geriatric medicine.

PA programs are accredited by the Accreditation Review Commission on Education for the Physician Assistant.

National Certification

The National Commission on Certification of Physician Assistants (NCCPA) is an independent organization established to assure the competency of physician assistants. In conjunction with the National Board of Medical Examiners, it administers a national certifying examination to graduates of accredited PA programs. Only those individuals who pass the exam may use the title “Physician Assistant-Certified” or “PA-C.” In order to remain certified, PAs must complete 100 hours of continuing medical education every two years and take a recertification examination every six years. In large measure, this private voluntary certification process has been adopted as a state licensing requirement.

Other medical organizations that have membership on the NCCPA Board of Directors include: the American Medical Association, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the American College of Surgeons, the American Hospital Association, the Association of American Medical Colleges, the Federation of State Medical Boards of the US, the National Medical Association, and the US Department of Defense.

Practice Settings

In the nearly 40 years since the first PAs began practicing the profession has shown remarkable growth. In 2007 there are an estimated 63,000 clinically practicing PAs in the United States. They are located in almost all health care settings and in every medical and surgical specialty.

In 2006 an estimated 231 million patient visits were made to PAs and approximately 286 million medications were prescribed or recommended. PAs have proven adaptable to the changes in medicine over the last quarter century and are filling roles that could not have been anticipated when the profession began. For example, many hospitals, faced with a shortage of medical residents or restrictions on resident work hours, have discovered the value of physician assistants.

Reimbursement

Medical and surgical services provided by physician assistants are covered under Medicare, TRICARE; and by most state Medicaid programs and private insurance companies. Medicare pays the PA’s employer for medical services provided by PAs in all settings. This includes hospitals (inpatient, outpatient, and emergency departments), nursing facilities, offices, clinics, the patient’s home, and first assisting at surgery. Assignment is mandatory and state law determines supervision and scope of practice.
Currently all 50 states cover medical services provided by PAs under their Medicaid fee for service or Medicaid managed programs. The rate of reimbursement which typically is paid to the employing practice and not directly to the PA is either the same as or slightly lower than that paid to physicians.

Most private payers do cover medical and surgical services provided by PAs. Some payers will separately credential and issue provider numbers to PAs. The majority of private payers ask that services delivered by PAs be billed under the name and provider number of the PA’s supervising physician. Most payers defer to state law when determining the services a PA can provide and supervision requirements. PAs do not duplicate, but rather extend the services provided by physicians.

9/07

Draft letter from Patient to Self-Insured Employer

[Date]

[Name of Director/Manager of Employee Benefits]
[Official Title]
[Company Name]
[Company Address]
[Company City, State & Zip]

Dear [Name of Director/Manager of Employee Benefits]:

I am an employee of [name of company] located in [city, state]. I recently received medical care that was provided by a physician assistant, [name of PA]. I was very pleased with the quality of care that I received. However, I have come to learn that our health plan has refused to pay for this service. The reason for this nonpayment seems to be the fact that [name of PA] is a physician assistant. I don’t understand the reason for this denial. [Name of PA] is a highly-trained physician assistant who is fully qualified and [use either licensed, registered, certified, or a combination of these, if applicable] in the state of [name of state] to provide medical care.

Why would my health plan refuse to cover a medically necessary service that was performed by a qualified health care provider? Physician Assistants do the following:

perform medical services that would otherwise have been provided by a physician;
provide services that are delegated to the physician assistant by the physician; and
deliver medical care in accordance with state law and always with physician supervision.

I am asking for your help in trying to resolved what appears to be a particularly irrational policy. I do not think that it is fair that I should have to personally pay for a medically necessary service that was performed to my satisfaction and logically should be covered under my health insurance plan.

Sincerely,

[Name of patient/employee]
[Claim number]
[Patient address & phone number]

SAMPLE LETTER SENT BY THE AAPA TO THE INSURANCE COMPANY FOR DENIAL OF CLAIM FOR SURGICAL SERVICES

[Date]

[Name of Claims Department Manager]
[Official Title]
[Insurance Company Name]
[Address]
[City, State & Zip]

Claim No.: ¬_______

Dear [Name of Claims Department Manager]:

We are contacting you in reference to the above mentioned claim [or claim denial] in which [name of insurance company] refused to pay the surgical first assistant fee for services provided by [name of PA]. [Name of PA] is a [use either certified, licensed, registered, a combination, if applicable] physician assistant (PA) who is fully qualified by education, training, and [name of the PA regulatory agency] to assist in surgery in the state of [name of state].

Due to the particular wording in [name of patient] policy, there may be no explicit contractual obligation for [name of insurance company] to pay for a physician assistant to first assist at surgery. However, it is important to understand that a physician assistant provides the same medical services that otherwise would be provided by a physician. PAs extend but do not duplicate the medical services provided by physicians.

The type of surgery that was performed on [name of patient], [type of surgery], does require the use of a surgical first assistant. The option is to have either a physician or a qualified non-physician, such as a PA, assist in the surgery. Government and other objective studies have shown that the quality of care to patients remains high when medical and surgical service are provided by a physician assistant. We would be happy to provide you with copies of these reports.

Clearly, the cost of providing the first assist duties does not increase (and may in fact be less) when a PA is used. In addition, when a surgeon is working with a PA that is familiar with the surgeon’s style the surgery can be completed in less time, resulting in a better outcome for the patient. For your information, enclosed is an excerpt from a report issued by the American College of Cardiology and The American Heart Association in March 1991. The report deals with guidelines for coronary bypass graft surgery. On page 565 (Section D, number 3), the report suggests that the use of surgical assistants should reduce the cost related to coronary bypass operations without reducing patient benefit or the quality of care. We believe that this conclusion is inferential on other types of surgery as well.

Perhaps there is some lack of familiarity with the PA profession. For your information, I have enclosed a summary that highlights the education, training, and certification process of PAs in surgery. A section on reimbursement in the summary indicates that Medicare, Medicaid, TRICARE/CHAMPUS and most private insurance companies recognize and reimburse PAs as first assistants in surgery.

Policyholder satisfaction is also an issue. The patient is placed in a difficult position. The patient doesn't understand why [his/her] health insurance policy will not cover medically necessary services provided by a competent, state authorized health care practitioner. If [name of insurance company] doesn't cover the fee for the PA who first assisted, then the financial burden may fall upon the patient.

The American Academy of Physician Assistants (AAPA) is the national professional association of the physician assistant profession. The AAPA represents more than 65,000 practicing PAs throughout the country. The use of PAs is growing rapidly within all segments of the medical community. Twenty-five percent of PAs practice in a surgical setting. There is no logical reason to deny this claim based on the quality of care, cost, or patient satisfaction.

We would appreciate having your comments on this matter at your earliest convenience.

Sincerely,

Michael L. Powe, Vice President
Health Systems and Reimbursement Policy

ACC/AHA TASK FORCE REPORT

[Refers to use of surgical assistants]

Guidelines and Indications for Coronary Artery Bypass Graft Surgery

A Report of the American College of Cardiology/American Heart
Association Task Force on Assessment of Diagnostic and Therapeutic
Cardiovascular Procedures (Subcommittee on Coronary Artery Bypass
Graft Surgery)

SUBCOMMITTEE MEMBERS
JOHN W. KIRKLIN, MD, FACC, Chairman
NICHOLAS T. KOUCHOUKOS, MD FACC
CARY W. AKINS, MD, FACC
BEN D. McCALLISTER, MD, FACC
EUGENE H. BLACKSTONE, MD, FACC
DAVID C. NAFTEL, PhD
DAVID C. BOOTH, MD, FACC
JOHN O. PARKER, MD, FACC
ROBERT M. CALIFF, MD, FACC
WILLIAM C. SHELDON, MD, FACC
LAWRENCE S. COHEN, MD, FACC
HUGH C. SMITH, MD, FACC
ROBERT J. HALL, MD, FACC
ANDREW S. WECHSLER, MD, FACC
FRANK E. HARRELL, Jr., PhD
JOHN F. WILLIAMS, Jr., MD, FACC

TASK FORCE MEMBERS
CHARLES FISCH, MD, FACC, Chairman
GEORGE A. BELLER, MD, FACC
ROMAN W. DESANCTIS, MD, FACC
HAROLD T. DODGE, MD, FACC
J. WARD KENNEDY, MD, FACC
T. JOSEPH REEVES, MD, FACC
SYLVAN LEE WEINBERG, MD, FACC

Preamble

It is becoming more apparent each day that despite a strong national commitment to excellence in health care, the resources and personnel are finite. It is, therefore, appropriate that the medical profession examine the impact of developing technology on the practice and cost of medical care. Such analysis, carefully conducted, could potentially have am impact on the cost of medical care without diminishing the effectiveness of that care.

To this end, the American College of Cardiology and the American Heart Association in 1980 established a Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures with the following charge:

The Task Force of the American College of Cardiology and the American Heart Association shall define the role of specific noninvasive and invasive procedures in the diagnosis and management of cardiovascular disease.

The Task Force shall address, when appropriate, the contribution, uniqueness, sensitivity, specificity, indications, contraindications and cost-effectiveness of such specific procedures.

The Task Force shall include a Chairman and six members, three representatives from the American Heart Association and three representatives from the American College of Cardiology. The Task Force may select ad hoc members as needed upon the approval of the Presidents of both organizations. Recommendations of the Task Force are forwarded to the President of each organization.

The members of the Task Force are: George A. Beller, MD, Roman W. DeSanctis, MD. Harold T. Dodge, MD, J. Ward Kennedy, Md, T. Joseph Reeves, MD, Sylvan Lee Weinberg, MD and Charles Fisch, MD, Chairman.

This document was reviewed by the officers and other responsible individuals of the two organizations and received final approval in October 1990. It is being published simultaneously in Circulation and the Journal of the American College of Cardiology. The potential impact of this document on the practice of cardiology and some of its unavoidable shortcomings are clearly set out in the introduction.
Charles Fisch, MD, FACC
0735-1097/91/53.50

Address for reprints: Michael Forcinito, Special Projects, American College of Cardiology, 911 Old Georgetown Road, Bethesda, Maryland 20814.

Guidelines and Indications for Coronary Artery Bypass Graft Surgery were approved by the American College of Cardiology Board of Trustees on October 14, 1990 and by the American Heart Association Steering Committee on October 18, 1990.
©1991 by the American College of Cardiology
JACC Vol. 17, No. 3
March 1, 1991: 543-89

C.    Precautions and Pitfalls

Identifying the cost of the coronary bypass operation, and comparing it with those of alternative forms of treatment, would appear to be a straightforward process. The charges for each hospital stay and professional contact could be gathered from computerized bills. These charges could then be totaled for some stated period of time and compared with those for coronary angioplasty, noninterventional medical treatment and other alternative forms of treatment. They could also then be compared according to geographic region, type and size of hospitals, method of practice (individual versus group practice), or method of billing (itemized versus global fee).

However, the variability in charges made for the coronary bypass procedure reflects both variability in actual costs, and variability in the proportion of the charge that comes from overhead and related factors. This is because the charge includes 1) the actual cost of performing the procedure, 2) the overhead for supporting those hospital or professional services whose actual costs exceed the reimbursement, 3) the overhead for meeting ongoing and often unrelated costs that must be shared among users of the institution, and 4) the overhead to cover projected costs of future expansion and equipment purchases in general. The differences between charges and costs, determined by a variety of actors, must be understood in assessing the financial impact of reducing or increasing the number of cardiac procedures performed.

Additionally, any consideration of restricting the use of the coronary bypass operation in patients in whom it is indicated must take into account other results of such restrictions. Patient disability will become greater. The accumulated costs of medication, recurrent hospital stays and subsequent myocardial infarctions and congestive heart failure will increase and may become greater than those of the coronary bypass operation.

In summary, any deliberate reduction in the number of coronary bypass procedures by rationing, in order to reduce costs, needs to consider the other fiscal, as well as human, effects of such a program.

D.    Recommendations

A concerted effort should be made by the medical profession to reduce the costs of the coronary bypass operation without reducing its benefits. Since it is a commonly performed operation about which a great deal is now known, areas in which significant cost reductions can be made without sacrifice in quality should be identifiable. Unnecessary components of care relating to the coronary bypass operation should be eliminated, and one mechanism for this is the forming of appropriate guidelines and indications for the coronary bypass operation. The difficulties of accomplishing these eliminations are recognized, and include the threat to the survival of some institutions and to the livelihood of some individuals in some specialties and areas of service.

The recommendations are as follows:

1. This report has described the variables (risk factors) upon which the recommendation for one or another form of therapy can appropriately be made (Sections IV, V, VI and X). Examinations and tests that do not relate directly to identifying the values of these variables (risk factors) should not be performed as service items, although they may be necessary in research protocols.
2. Redundancy in the provision of services within an institution should be avoided.
3. Properly trained surgeon’s assistants, rather than fully qualified surgeons, have been demonstrated to be highly competent in removing saphenous veins, opening and closing surgical incisions, acting as first assistant during CABG operations and participating in preoperative and postoperative care under the supervision of qualified cardiothoracic surgeons. Since the length of the educational process leading to qualifications as a Surgeon’s Assistant in cardiothoracic surgery is much shorter than that leading to the MD degree and qualification as a cardiothoracic surgeon, and the overall responsibilities are less, the compensation of this group of health care workers is considerably less than that of qualified surgeons. More widespread substitution of surgeon’s assistants, in both teaching and nonteaching settings, should reduce the costs related to the coronary bypass operation without reducing patient benefit and the quality of care.
4. The postoperative care of the majority of patients undergoing routine coronary artery bypass grafting is simple and straightforward. Particularly in such patients, unnecessary components of care and testing should be avoided.
5. Complications may increase costs in all areas, and therefore before, during and after the operation techniques and practices that reduce complications without endangering comparative benefits should be used.

X. Patient-Specific Guidelines and Indications for the Coronary Artery
Bypass Operation

General information on outcome after the coronary artery bypass operation is contained in Section III, but it is not specific to any given patient because a number of risk factors determine the outcome in specific patients. Comparisons between outcome after the coronary bypass operation and noninterventional medical treatment are presented in Section IV, and comparisons between outcome after the coronary bypass operation and coronary angioplasty in Section V. These comparisons are group-specific and not specific to an individual patient and, although more helpful than simple

KIRKLIN ET AL. 565
ACC/AHA TASK FORCE REPORT

PHYSICIAN ASSISTANTS IN SURGERY

Physician assistants (PAs) practice medicine with supervision by licensed physicians, providing patients with services ranging from primary medicine to very specialized surgical care. A physician assistant’s scope of practice is determined by state law, the supervising physician’s delegation of responsibilities, the PA’s education and experience, and the specialty and setting in which the PA works.

Physician Assistant Education

PAs are educated in accredited programs located at schools of medicine or allied health, universities and teaching hospitals. Prerequisites for admission generally include two years of relevant college course work, plus patient care experience. PA education is an average of 26 months in length. The typical student has a bachelor’s degree and nearly 4 years of health care related experience before entering a PA program.

The first phase of the program consists of intensive classroom and laboratory study, providing students with an in-depth understanding of the medical sciences. Subjects include anatomy, pharmacology, physiology, clinical laboratory medicine and microbiology, pathophysiology, physical diagnosis, medical ethics and behavioral sciences. The second phase consists of clinical rotations with physician preceptors in a variety of settings, such as hospitals, long term care facilities, and physicians’ offices. Most programs require clinical rotations in internal medicine, family medicine, surgery, pediatrics, obstetrics/gynecology, psychiatry, emergency medicine and geriatric medicine.

PA programs are accredited by the Accreditation Review Commission on Education for the Physician Assistant.

National Certification

The National Commission on Certification of Physician Assistants (NCCPA) is an independent organization established to assure the competency of physician assistants. In conjunction with the National Board of Medical Examiners, it administers a national certifying examination to graduates of accredited PA programs. Only those individuals who pass the exam may use the title “Physician Assistant-Certified” or “PA-C.” In order to remain certified, PAs must complete 100 hours of continuing medical education every two years and take a recertification examination every six years. In large measure, this private voluntary certification process has been adopted as a state licensing requirement.
Other medical organizations that have membership on the NCCPA Board of Directors include: the American Medical Association, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the American College of Surgeons, the American Hospital Association, the Association of American Medical Colleges, the Federation of State Medical Boards of the US, the National Medical Association, and the US Department of Defense.

Practice Settings

In the nearly 40 years since the first PAs began practicing the profession has shown remarkable growth. In 2007 there are an estimated 63,000 clinically practicing PAs in the United States. They are located in almost all health care settings and in every medical and surgical specialty.

PAs are employed in both inpatient and outpatient settings. They may be employed by private practices, managed care organizations, or hospitals. Hospitals that have no residents often hire PAs to act as house officers. Teaching hospitals hire them to work with residents and house physicians, providing continuity on the surgical service and freeing residents to focus on complex and varied cases.

A recent survey of the Association of Physician Assistants in Cardiovascular Surgery found that saphenous vein harvesting is their most common responsibility (94%), followed by first assisting (91%), surgery call (85%), step-down coverage (80%), discharge summaries (79%), performing histories and physicals (78%), ICU patient care (73%), radial harvesting (70%), and patient education (65%).

In 2006 an estimated 231 million patient visits were made to PAs and approximately 286 million medications were prescribed or recommended. PAs have proven adaptable to the changes in medicine over the last quarter century and are filling roles that could not have been anticipated when the profession began. For example, many hospitals, faced with a shortage of medical residents or restrictions on resident work hours, have discovered the value of physician assistants.

Reimbursement

Medical and surgical services provided by physician assistants are covered under Medicare, TRICARE; and by most state Medicaid programs and private insurance companies. Medicare pays the PA’s employer for medical and surgical services provided by PAs in all settings. This includes hospitals (inpatient, outpatient, and emergency departments), nursing facilities, offices, clinics, the patient’s home, and first assisting at surgery. Assignment is mandatory and state law determines supervision and scope of practice. First assisting at surgery claims are reimbursed at 13.6% of the primary surgeon’s fee (85% of the physicians fee schedule).

Currently all 50 states cover medical services provided by PAs under their Medicaid fee for service or Medicaid managed programs. The rate of reimbursement which typically is paid to the employing practice and not directly to the PA is either the same as or slightly lower than that paid to physicians.

Most private payers do cover medical and surgical services provided by PAs. Some payers will separately credential and issue provider numbers to PAs. The majority of private payers ask that services delivered by PAs be billed under the name and provider number of the PA’s supervising physician. Most payers defer to state law when determining the services a PA can provide and supervision requirements. PAs do not duplicate, but rather extend the services provided by physicians.

9/07