Recovering claim dues from payers for physician assistance claims requires intricate knowledge of payer-specific guidelines. Medical Billing Wholesalers’ denials research team helped the client identify and resolve out-of-network claims.
ViewPoint
Billing for Physician Assistants (PA) requires intricate knowledge of payer-specific guidelines. Medicare pays the PA’s employer for medical and surgical services provided by PA’s in all settings at 85 percent of the physician’s fee schedule. According to the guidelines, settings include hospitals (inpatient, outpatient, operating room, and emergency departments), nursing facilities, offices, clinics, the patient’s home, and first assisting at surgery. Medical Billers need to understand and recognize some of these nuances to ensure that they get accurate reimbursements on time, all the time.
Results Summary
Customer Situation
A New Jersey-based physician practicing with more than ten practitioners was getting almost all its PA claims denied resulting in the loss of over $36 K per month. Lack of clarity on submission guidelines related to PA claims for specific payers – Oxford and UHC- contributed to the pile-up of these denied claims.
Challenges with Prolonged Service Claims
We faced two major challenges Since the provider group is out-of-network with the payers, both UHC and Oxford, the insurance reps were not able to provide any resolution for the denial.
- While Medicare guidelines require all P.A. claims under their name along with supervising physician’s name in Box 17, payers such as UHC & OXFORD may deny P.A. claims citing the reason as being outside the scope of the healthcare provider’s License.
Guidelines for Physician Assitant Claims
Medicare guidelines are important to follow where PAs are concerned. Medicare pays the PA’s employer for medical and surgical services provided by PAs in all settings at 85 percent of the physician’s fee schedule. According to the guidelines, settings include hospitals (inpatient, outpatient, operating room, and emergency departments), nursing facilities, offices, clinics, the patient’s home, and first assistants at surgery.
Solution
After researching payer-specific guidelines across multiple payers, we developed detailed instructions for different payers and coached our team members on filing these claims.
- Guidelines for the submission of Physician Assistant Claims
- Most insurances have specific instructions for processing Physician Assistants (P.A.) claims. Physician Assistants cannot see patients individually without assistance from the supervising physician.
- Few insurances require PA claims under their name in rendering physician box along with supervising physician name in Box 17 on HCFA1500.
- Few insurances require PA claims under the supervising physician name along with several modifiers per the insurance guideline.
- Payer Specific Guidelines – UHC and Oxford
- These payers require that PA claims must be billed under supervising physician’s name along with modifier SA.
- We worked with the practice team to rebill the denied claims and submitted the claims under the supervising physician’s name
Reduction in Physician Assistant Claim Denials.
Reduction of claim denials from 73 claims out of 106 to 11 claims out of 49 claims.
Results
- Once we ascertained the guidelines, all the existing denials around more than 90 claims amounting to $80 K in charges were refiled and collected for out of network rate.
- All new PA claims are now being submitted and paid under the supervising physician’s name for these payers, and it reduces denials ratio and boot up the monthly collection as well.
- For the out of Network providers, UHC & Oxford insurances repriced the claims for 60% of billed charges.
