Reimbursement for Your Performance

Reimbursement for Your Performance 

In the past, PAs have not been given much attention to reimbursement, specifically the requirements of of coding, documentation, and the rules of reimbursement affecting whether YOU are going to get reimbursed for your services as a PA. This is IMPORTANT!

How Is Our Healthcare Reimbursement System Structured?

Medicare sets the standard policy - the rules of the game which everyone should follow. There are then 14 Medicare Administrative Contractors (MACs), which basically function as individual branches that enforce policy around the country, by state or region. This system is sort of like how our government works, with a few differences. The rules come from the capital in D.C. and then each state is responsible for enforcing the rules, but here, the MACs are responsible for enforcing the rules in a way they interpret them. Medicare HMO (health maintenance organization) products are written by private carriers - they basically follow the rules of Medicare with a few changes to the policy as they see fit. Private insurance companies like Blue Cross/Blue Shield, UnitedHealthcare, Cigna, Aetna, and Humana, provide policies with various combinations of benefits, and are not required to follow Medicare policies, which is the practice of "free enterprise" we have in the US. This also means they're not required to follow the coding practices for the Current Procedural Terminology (CPT) or the International Classification of Diseases, 9th Clinical Modification Edition (also known as ICD-9). If you know anything about healthcare, these codes are used to say, "okay, this procedure is for excision of the sigmoid colon due to diverticulitis." There is a corresponding CPT and ICD-9 code that represents medical, surgical, and diagnostic services to communicate with everyone - clinical, financial, administrative, etc.

What's the big deal?

The problem is that PAs can encounter different codes from different carriers, especially private carriers who do not have to use the same coding systems as everyone else. That's what makes reimbursement a "moving target." In addition, on OCTOBER 1, 2014, the entire US will make the largest change diagnostic coding will see in our careers. We will switch over from ICD-9 to ICD-10. This can only mean better healthcare outcomes for our patients. For example, with ICD-10, more diagnoses are going to be implemented into the current system of codes, but also, more descriptive diagnoses. This means that when you go to choose a code matching your diagnosis, it should be less likely to be shot back from the carrier reimbursing your services. In addition, also means that YOU as a PA need to learn the required documentation requirements and stay up-to-date on your responsibilities, especially changes in policy in your area. Your salary, bonuses, and eventually, the ability to provide valuable, quality healthcare to your patients could be affected. This could be huge for the practice of medicine, and not for just PAs!