Tom Zampieri PA-C  tzampieri@houston.rr.com
Executive Director VAPAA

as Executive Director of the Veterans Affairs Physician Assistant Association, we have different problems than the state chapters. The other federal chapter PA's all probably would agree that the federal PA's have some problems, in that most agencies for employment and for clinical practice as a PA do not regulate the PA's by the state laws, and do not require a state license to be in the agency. The military, PHS, Coast Guard, and VA do not require a state license.

The problem we also have is that any PA provided services to a patient no matter what federal agency, is billed by the Federal government agency, and
the insurance company or third party, or for that matter any deductable the patient must pay, goes not to the MD or PA but to the federal agency, and in
some cases to Department of Treasury!

We are in the process though of trying to get the problem addressed, that many PA's are being told to get a state license, just to get a Medicare PIN
number for the purpose of billing for their services.

We would rather have the third party insurance companies accept a Federal Facility Number for the PA, so we are not required to get a license, which
is expensive, time consuming, and does not benefit the federal PA because the money collected goes not to the provider or his supervisor but to the
federal government!

Why pay for a $500 license in Mississippi as a VA employed or Department of Defense PA so the federal government can administratively bill for your
services, and the agency will NOT reimburse PA's for the expenses of obtaining the licenses.

I have to agree with Mr. Zampieri. The federally employed PA (whether in the VA, PHS, IHS, State Department, CIA, BOP or DoD) works under a significantly different practice relationship than the civilian PA. Our situations take us where we are working with physicians who are able to be licensed from ANY state. As such, were we to be required to hold a state license, a large majority of us would not be able to do so as no single state will issue a "full, valid, current and (most importantly) unrestricted" license to a PA under those conditions. The DoD lawyers recently conducted a survey of all 50 states asking questions to that effect, and did not receive one affirmative reply from any state. Reimbursement based upon state licensure would create an unfair situation for these federally employed PAs and it is one that would keep PAs from joining federal service, thus leaving the gap for other practitioners (possibly less qualified) to swallow up all those positions. This is unacceptable. 

The AAPA needs to realize this and support us in this effort. Already they have started in this, but there is so much more yet to do. One thing is the upcoming amendment to the House of Delegates in New Orleans that the VA is sponsoring. The VA feels that this is a very positive step that will benefit all federally employed PAs and doing so will only strengthen our position in the arena of medical professions. I ask all the other chapters to support it.

Last year the VA was able to recoup around 1.5 billion dollars in collections for reimbursement of professional services. They envision that will increase to about 2.5 billion dollars by next year. If PAs are not included in the practitioners allowed to bill for services, the VA will quickly realize there is no reason to keep us and will find other practitioners to take our place. Allowing a credentialling process that includes graduation from an ARC-PA approved PA school and NCCPA certification should be adequate for insurance companies when assessing the qualifications of a PA. The VA already has invoked federal supremacy for all non-scheduled medication ordering and prescribing, and for inpatient Scheduled medication ordering. If there is no way to resolve this licensure issue, whether for prescribing or reimbursement, for ALL federally employed PAs, there will soon be a void in the area of federal medicine from which the PA community will never recover. We need to prevent this from happening NOW. 

Thank you for allowing me to express my concern about this issue. 
Joseph Streff 
Joseph.Streff@med.va.gov 
 

On October 25, new rules released by the Centers for Medicare and Medicaid Services (CMS, formerly known as the Health Care Financing Administration {HCFA}) offer PAs and their supervising physicians increased latitude in billing for evaluation and management (E/M) services provided in the hospital setting. Responding to serious concerns by AAPA and other medical specialty groups, CMS substantially altered its policy involving the coverage of E/M hospital services when provided jointly by a PA and a physician to the same patient on the same day.

The new policy, detailed in Medicare Transmittal 1776 (http://cms.hhs.gov/manuals/pm_trans/R1776B3.pdf), allows E/M services
provided by a PA and a physician in the hospital (inpatient, outpatient, or in the ED) to be combined for billing purposes. The combined services may be billed under the name and Medicare provider identification number (PIN) of the physician at 100 percent of the fee schedule, as long as the physician provides any portion of the E/M service during a face-to-face encounter with the patient. The policy does not get specific as to the percentage of care that must be provided by the physician. The policy also requires that the physician and PA work for the same employer, practice, or hospital.

The new policy eliminates the "split billing" requirement. A September 2001 Medicare transmittal required that split billing be used to separately
document and bill for E/M services provided by a PA and a physician when both provided care to the same patient on the same day. AAPA alerted CMS officials to the administrative and billing difficulties that this requirement would cause for both health care professionals and Medicare
carriers, and a CMS review of the split billing rule was initiated. Prior to the split billing requirement, Medicare rules for hospital billing
required that the health care professional who provided the majority of the professional E/M service to the patient be the one under whose name and
number the bill was submitted; if the PA did most of the work for the patient, the service was billed under the PA's name and PIN. The
reimbursement was 85 percent of the fee schedule.

The new policy allows PAs and physicians to share visits made to patients with the combined work of both covered at 100 percent of the fee schedule. That is, if the PA provides the majority of the service for the patient and the physician provides any face-to-face portion of the E/M encounter, the entire service may be billed under the physician's name and PIN. The new rule does not extend to procedures performed in the ED or the hospital. The practitioner who does the majority of a procedure is the one under whose name and PIN the procedure should be billed.

If the physician is not present for any face-to-face portion of the E/M encounter, the service is appropriately billed under the PA's name and
Medicare PIN, with reimbursement at the 85 percent rate. When billing for hospital services provided by PAs under the PA's name and PIN, Medicare does not require the on-site presence of the supervising physician; access to telephonic communication is sufficient. Always check with your state law and hospital policies, which may be more restrictive than Medicare's policies. Also, this rule change is specific to Medicare. Check with your individual private payers to ascertain their specific billing requirements.

By Michael Powe
Director, Health Systems and Reimbursement Policy
American Academy of Physician Assistants
http://www.sempa.org