PAs, NPs Become 'Medicare Ghosts' Billing Under a Physician

Ingrid Hein

September 09, 2019

Advanced practitioners who bill for medical services under a physician's name become ghosts in the nation's medical database, which means that what they do and the value they add cannot be tracked.

Medicare Part B incident-to billing is something of a quagmire, said Todd Pickard, PA-C, director of physician assistant (PA) practice at the MD Anderson Cancer Center in Houston, Texas.

If PAs and nurse practitioners (NPs) bill using their national provider identification number, their institution is reimbursed at 85% of the Medicare physician fee schedule.

However, they can bill at 100% of the physician fee schedule if "the doctor is in the building," Pickard told Medscape Medical News. As long as the patient has already been seen by the physician and is receiving ongoing treatment, incident-to billing is allowed.

"But when the bill and the data are all linked to the doctor, that makes it challenging to find out how much work PAs and NPs are actually doing," he explained. The work gets done and the insurer pays, but nobody knows who did that work. "The PA gets whitewashed by the system," Pickard said.

The PA gets whitewashed by the system. Todd Pickard, PA-C

During a session at the Association of Physician Assistants in Oncology (APAO) 2019 Annual Symposium in Boston, Massachusetts, Pickard described the frustration he experienced when he participated in a research project to identify the personal and practice characteristics of advanced practice providers (APPs).

He and his fellow researchers identified 5350 oncology APPs, including PAs and NPs, but concluded that there were likely more than 7000 advanced practitioners in oncology (J Adv Pract Oncol. 2018;9:585-598). However, medical records did not allow them to determine either the precise number of APPs or their activity.

Varied Services

In a recent report to the US Congress, the Medicare Payment Advisory Commission recommended putting an end to incident-to billing, as reported by Medscape Medical News. The American Association of Physician Assistants and the American Association of Nurse Practitioners voiced support for the recommendation, but the American Medical Association opposed it.

"As we move into more value-based care, there is a need to better track the quality of each provider so we know how they are contributing," said Alisha DeTroye, PA, director of PA services at Wake Forest Baptist Health in Winston-Salem, North Carolina, and president-elect of North Carolina Academy of PAs.

"If the bill goes out through physicians, the PA contribution is difficult to track," she explained.

PAs have a wide range of expertise and hone their skills according to the needs of their workplace. "We are the stem cells of medical practice," Pickard said. "We become an expert at the part we practice; we fill in wherever we're needed."

The ability to track PA services is complicated by state, institutional, and supervising-physician expectations.

If you ask how many patients PAs see and what PAs do, "I can only give you a complicated partial answer," Pickard said.

"We've done a lot of work to engage with CMS [Centers for Medicare & Medicaid Services] and Blue Cross and all the payers to help them understand that we have no way of measuring who's done what work," he added.

Some progress has been made at his hospital, he told Medscape Medical News. The latest electronic medical record system captures the service provider separately from the billing, although the national database does not. "At least half our patients are Medicare patients, so there's a huge amount of data the CMS is missing.

"But if I was in a rural area, there wouldn't be the administrative resources to deal with this," he said. "In rural El Paso, there's no billing compliance lawyer. Maybe you'll have one practice manager and one back-office person. That's when having a PA can seem complicated."

"Random" Restrictions

Legislation and guidelines are slowly being changed so as to include the PA, but sometimes the changes don't make sense. In fact, "some restrictions are random," said DeTroye.

For example, when caring for patients with diabetes, "we can diagnose you, amputate your leg, prescribe insulin, but we cannot order diabetic shoes," she pointed out. "Sometimes you think you have it all solved, and then there's a blip on the radar that can cause challenges," she said.

But that is part of the profession's growing pains, she said.

"When I first started as a PA in oncology 15 years ago, resident hours had become restricted, which opened up places in the inpatient setting for PAs," DeTroye explained. With an aging population with an increased demand for oncology care, "there's been a lot of growth in PA-led services, from chemotherapy to acute needs."

With an increase in the number of practicing PAs comes greater recognition, which pushes guidelines. This gives PAs their full capacity to practice.

PAs now have some recognition as attendings in a hospice setting, as reported by Medscape Medical News.

"That's another big win that used to be a challenge," DeTroye said. "In the end, it is most cost-effective to have everyone working to their full scope."

Pickard and DeTroye have disclosed no relevant financial relationships.

Association of Physician Assistants in Oncology (APAO) 2019 Annual Symposium. Presented September 1, 2019.

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