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A "Friendly" Offer by Insurance Companies?
An increasing number of insurance companies and third party payers are offering practices the option of receiving their reimbursement via direct deposit. The Medicare program offers such an option and it works well for most practices.
But not every payer provides the same level of transparency in the payment process. When evaluating whether to accept this option from payers other than Medicare, make sure that the payer provides adequate notice as to when a payment is made, and that it is reasonably easy to identify the specific services that are being reimbursed within that payment including resubmitted claims.
AAPA Comments on Medicare's Fee Schedule Proposals
AAPA submitted formal comments to the Centers for Medicare and Medicaid Services (CMS) regarding the 2010 Physician Payment Schedule Proposed Rule. The proposed rule contains potential Medicare payment and policy changes for the upcoming year as suggested by Medicare officials, often in cooperation with requests from professional medical societies. After a 60-day public comment period Medicare officials then decide if their proposed changes will be officially adopted, abandoned, or altered based upon comments received from medical organizations, such as AAPA and the American Medical Association, individual health care professionals, the public and other stakeholders.
AAPA's comments:
- Supported proposed policy changes that would allow PAs to supervise all outpatient therapeutic services, and encouraged CMS to adopt the same policy with respect to intensive cardiac rehab, cardiac rehab, and pulmonary rehab services;
- Agreed with CMS on increasing the payment for the Welcome to Medicare exam;
- Applauded the inclusion of PAs as health care professionals who can provide education for chronic kidney disease;
- Concurred with the clarification that PAs are eligible to enroll and prescribe in Medicare's Competitive Acquisition Program, which covers the cost of certain drugs provided to Medicare beneficiaries;
- Supported the implementation of provisions that will move Medicare coverage for behavioral and mental health services toward full parity with coverage for other medical conditions; and
- Agreed with the proposal to eliminate consultation codes, but questioned why the proposal did not allocate a greater portion of the reimbursement dollars from consults to initial visit office and hospital CPT codes.
CMS will issue the final rule on November 1. Policy changes in the final rule are typically effective on January 1, 2010.Rumor Control on
PA Ownership under Medicare
It seems that every so often there is a challenge, or rumor of a challenge, to the ability of PAs to have an ownership interest in a practice or corporate entity that is eligible to bill the Medicare program. Many of these rumors have some basis in fact, and require that AAPA and PAs provide education and historical context to Medicare carriers and/or national Medicare officials surrounding the issue of PA ownership.
In 2003, AAPA staff and a few individual PAs worked to change Medicare's policies that at the time did not allow PAs to have any ownership in a practice or corporate entity that billed Medicare. By May of 2003, AAPA had an agreement with the Centers for Medicare and Medicaid Services (CMS) that allowed a PA to own up to 99% of a state-approved entity that could bill the Medicare program. The stipulation was that a non-PA had to own at least one percent of the entity.
Most recently, statements from the Florida Medicare carrier, First Coast, suggested that at least five percent of the corporate entity had to be owned by a non-PA. AAPA Reimbursement Department staff and Hamilton Boone, PA-C, reimbursement coordinator from the Florida PA chapter, contacted Medicare officials to express concern over any policy that would reduce the previously agreed upon ownership percentage for PAs.
Word has come from senior CMS officials that there will be no change in policy and the ownership share of up to 99 percent for PAs remains in effect.
Billing for Administration of H1N1 Vaccine
Officials at the Centers for Medicare and Medicaid Services (CMS) have clarified payment policy for the seasonable influenza virus vaccine, and established coverage and reimbursement rules for the H1N1 vaccine.
Medicare Part B covers the seasonal influenza virus vaccine when provided to Medicare beneficiaries. Payment for that vaccine will be made even if the administration of the "traditional" seasonal vaccine occurs earlier in the year than usual. Beneficiaries are not charged a deductible or co-pay for the vaccine or its administration.
The H1N1 vaccine will be available to Medicare beneficiaries as an additional preventive immunization service. It is expected that practices will receive the H1N1 vaccine at no charge. Therefore, Medicare will only pay for the administration of the vaccine.
CMS created two new codes for H1N1 which became effective on September 1, 2009:
- G9141 - influenza A (H1N1) immunization administration (includes counseling the patient/family)
- G9142 - influenza A (H1N1) vaccine, any route of administration (This code is for the vaccine itself. Since the vaccine will be provided to practices free of charge, G9142 will not be used as a billing code.)
Medicare will generally pay for both a single dose of the seasonal flu vaccine and its administration, and for one or more administrations of the H1N1 vaccine (but, not the H1N1 vaccine itself if that vaccine is supplied to health care professionals free of charge). Note, if the beneficiary's only purpose for a visit to the practice is to receive a vaccine, no evaluation and management office visit may
be billed.
The H1N1 vaccine is expected to be available in October. For more information on the H1N1 flu, refer to the CDC Website or call 1-800-CDC-INFO (800-232-4636), TTY: (888) 232-6348, 24 hours a day, 7 days a week.
Reimbursement Watch is a bi-monthly newsletter written by Michael Powe, AAPA Vice President of Health Systems and Reimbursement Policy. You are more than welcome to reprint items, just credit American Academy of Physician Assistant's Reimbursement Watch. Your comments, questions, and suggestions are welcome. Phone 703-836-2272 ext. 3211, Fax 703-684-1924 or Write: AAPA 950 North Washington Street, Alexandria, VA 22314-1552. E-mail address: This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
