Best Practices in filing Physician Assistant Claim enable Recovery of over $80 K in out-of-network claims
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 Physician Assistant 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.
Solution
Reduction in Physician Assistant Claim Denials.
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
Results
We were able to achieve the following results with concerted education of the provider's coding team and focus on A/R resolution.
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.
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Our focus on resolving denials by identifying and systemically eliminate the root causes, helps our clients improve revenue by a minimum of 20%. To learn about how we can help you reduce denials and improve all your revenue cycle KPIs, please fill the form below and we will be in touch.
