A neurosurgeon frequently schedules a physician’s assistant to assist in surgical procedures. In addition, the neurosurgeon assists with pre and post-operative patient care. The physician’s assistant works under the constant supervision of the physician. In many situations, the PA’s involvement in the surgical procedure avoids the need to schedule an assistant surgeon for the procedure. All claims are filed under the physician’s tax identification number.
The neurosurgeon has a few carriers which frequently deny coverage for the physician’s assistant. However, all such denials are routinely appealed. The neurosurgeon’s staff appeals the denials with a copy of the operative report and a copy of the Physician’s Assistant license. The appeal describes in detail the medical services performed by the physician’s assistant.
The majority of these denials are overturned on the initial appeal. However, claims that are denied by an appeal reviewer are appealed a second time with a request that the medical director review the medical records and address whether the care meets the medical necessity definition in the plan or policy.
Physicians Assistant’s charges are increasingly accepted by most major carriers. The Balanced Budget Act of 1997 recognizes PA’s as Medicare covered providers in all practice settings at 85 percent of the physician’s fee schedule. This change, effective January 1, 1998, raised the reimbursement rate for PA first assistants from 65% to 85% of the physician fee schedule. Certain “incident to” services qualify for 100 percent reimbursement.
Further, use of a physician extender, a physician’s assistant of nurse practitioner, has doubled the past decade according to some surveys. The Physician’s Advisory polled their readers last year regarding use of physician extenders. They found that 84 percent of primary care physician readers used one or more physician extenders in their practice and 100 percent of multi-specialty groups were utilizing physicians extenders.
However, some third party carriers still do not routinely reimburse practices for physician extender services and many offices still do not file claims for such services.
How to Appeal
When appealing such denials, it is important to provide information to support the medical necessity of the care given. Ask the doctor for case specific information regarding the need for a physician assistant. For example, if the physician’s assistant operates surgical equipment which leaves the surgeons hands free to perform the surgical procedure, provide this information in the appeal along with supporting documentation for the medical records.
Further, it is beneficial to cite your state law regarding the practice of physician’s assistants. According to the American Academy of Physician Assistants, every state, except Mississippi, has enacted detailed statutes and regulations that define physician’s assistants, describe their scope of practice, discuss supervision, designate the agency that will administer the law, set application and renewal criteria, and establish disciplinary measures for specified violations of the law. A summary of each state’s Physicians Assistant statute is accessible at the AAPA web site: www.aapa.org/.
Your appeal letter will be very persuasive if the local PA statute is cited and an explanation is given as to how the services provided fall within the scope of the Physician’s Assistants license. Also, provide a copy of the license to establish the credentials of your medical personnel.
Finally, if the services represent the most cost effective approach to the medical service without sacrificing quality of care, be sure to mention this in your appeal letter. Find out if the carrier would have approved an assistant surgeon for the procedure. If so, this may also support you argument that the physician’s assistant claim should be reimbursed. If the denial is maintained, ask the insured party to also appeal the denial along with any information in the policy or plan which appear to support the payment of the claim.
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