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!

New Certification Process for PAs

New Certification Process for PAs 

It's a new year, and whether fortunately, or unfortunately (i'll let you make that opinion yourself), there is a new certification process in 2014 for physician assistants. The National Commission on Certification of Physician Assistants (NCCPA) originally instituted the recertification exam for PAs in the 1980s, and this is the first major change since then. The new process includes a switch from a 6 year recertification process to a 10 year certification process. These changes are taking place for three groups of PAs:

1. People certified for the first time (probably YOU, students reading this blog)
2. People certified AGAIN after a lapse in certification (have you left practice for a few years due to medical leave of absence? possibly a leave of absence for childcare reasons?)
3. People who complete a 6-year certification maintenance cycle in 2014

If you don't fit any of these categories, you will transition to the 10 year cycle as you complete the 6-year certification maintenance process already in progress. 

What's the Same?

• Still required to earn/log 100 CME credits during every "2-year" CME log cycle
• Those 100 CME credits must include 50+ Category 1 credits
• PANRE exam still at the end of the process

New Updates

PAEA Program Directory

Physician Assistant Education Association Program Directory

Updated: 09/17/2018
What is the PAEA Program Directory? The national organization for PA educational programs launched a pretty inclusive directory of all PA programs. Individual programs update the information themselves and update the information according to a survey given out each year by PAEA. The directory can be accessed at http://directory.paeaonline.org. The cost is now FREE and more information about joining can be found at http://directory.paeaonline.org/about. The directory allows you to access information about all PA programs nationwide including:

• Costs
• Accreditation (provisional or probationary, even those in development)
• Type of degrees offered (associate's, certificate, bachelor's, master's)
• Admission exam requirements (GRE, TOEFL)
• Whether the program accepts international applicants
• Veteran benefits
• Preprofessional programs
• Programs that offer part time options
• Programs that participate in CASPA

Figure 1. This particular search shows the PAEA directory by Texas schools that offer Master's degrees requiring the GRE that participate with CASPA. The search results are displayed. As you can see the status of all 4 programs is accredited. If you click on one of the programs, you can learn more about each. 

When you click on an individual school, you can view accreditation status (including their original accreditation date or any recent loss of accreditation/probation), mission and notable features, preprofessional & online masters degrees, websites and social media, veterans information, class & degree information, information for international applicants, application deadline information, curriculum and coursework focus, contact information, TUITION COST, standardized exam requirements, healthcare experience, minimum GPA, recommendation letters, supplemental application information, and pre-requisite coursework. 

Here is a snapshot of UT Southwestern in Dallas' profile:

Figure 2. This example shows a sample of UT Southwestern's profile taken from PAEA's Program Directory. It clearly displays the GPA requirements, recommendation letters, and supplemental application information. 

So, why do I need this? 

As a pre-PA student, this directory is important. This is a vital resource to helping you select which program best fits your needs. I know it was extremely helpful for me. It lays out a lot of the basic information when choosing a school and in a way levels the playing field so that you can focus your time and energy getting to know the cities, the rotation sites, and the faces behind the program you are interested in rather than class size and PANCE scores. It allowed me to focus my attention on finding specific questions to ask schools at interviews and information sessions. So, don't sweat the small stuff. Use the resources that were created to help you. 

Cover Your Ass, Assets That Is

As a PA you may be curious about liability insurance, maybe something a student or pre-PA student may not be as worried about, but definitely something to consider for the future. Recently, AAPA endorsed the use of a personal professional liability insurance policy. 

What does this mean for PA's? 

This means protection for YOU against malpractice allegations. Think about this, the flip side is that your employer provides insurance that insures you on their policy, either specifically or generally. 

What can YOU do?

When looking for a job, ask your employer to reimburse you for a personal professional liability insurance policy for protection against malpractice allegations. If the company does not agree to the terms, you may have to pay out of pocket. This may be an intelligent decision considering malpractice lawsuit costs can soar high above what your employers insurance may cover, dipping into your own PERSONAL assets. After all, malpractice means YOU are ultimately responsible for any errors or omissions inuring your patients. 

What's the CATCH?

The catch is that most insurance plans have premiums too high to afford your own personal insurance and this is because insurance companies know you're already covered by your employer for some amount. 

What's the SOLUTION?

AAPA Insurance Services offers PA's already covered by an employer's group policy a professional liability policy at a discount. This can be as low as $2 per day! This is important if you want to protect YOUR OWN assets at the end of the day - yes, this means your money, $aving$, etc! Because your employers insurance policy isn't about YOU, it's about THEM. When insurers pay out settlements and verdicts, those payments go to the National Practitioner Data Bank and that amount is divided among each defendant (physicians and PA's responsible for malpractice) based on an assessment of who was most responsible for the error. If you are not represented during the negotiating, you will have no say in how much fault is attributed to you, and thus, you could owe lots! Better hope your employer likes you!!  

Tell me MORE. 

This new plan does NOT replace the old one, but it is in addition to what your employer already provides for you and it is also NOT conditional on whether your employers insurance policy stands or fails on you. The plan has a limit maximum liability of $100,000, but legal fees are covered in ADDITION to that amount. This means that even if you settle for $180,000, but your fees cost $700,000, the fees are covered. Keep in mind that this also means that this $180,000 would be more than your plan is worth, so you'd count on your employers insurance to pay the extra $80,000. I hope that makes sense. This is a great example of how important personal liability insurance policies are to protect your own assets. 

The Affordable Care Act and Physician Assistants

How is the ACA going to affect me as a PA? How is the ACA going to affect my patients?

By: Paul Gonzales

These two questions were posed in an article written in the september issue of PA professional. I think they're both very important questions for pre-PA students, current students, and practicing PA's. If you don't know what the ACA is - the Affordable Care Act is what people are calling ObamaCare. The terms are interchangeable, incase you were wondering. Signed into law March 23, 2010, the ACA quickly implemented changes such as the following below. In addition, the grand impact of the ACA was to decrease the number of uninsured Americans by as many as 32 million people. Highlighted in red are a few impacts that relate heavily to PA practice. I encourage you to read through all of them.

• Cover children younger than 19 regardless of pre-existing conditions (2010)
• Young adults can now stay on their parents insurance until they are 26 (2010)
• Access to insurance for uninsured individuals with pre-existing conditions (2010) - some people who have be uninsured for 6+ months have trouble finding insurance because of existing conditions
• Scholarships and loan repayment plans (2010) - primary care practitioners have access to repayment or loan forgiveness programs to increase the primary care workforce
• Increased federal payments to providers in rural areas (2010)- this includes PA's who work in rural areas; examples are Medicare, Medicaid, Children's Health Insurance Program

Meet the Author

Updated: 01/15/2018

My name is Paul Alexander Gonzales, and I am currently a certified Physician Assistant living in Dallas, TX (note: I was a PA student in 2014 when I started this blog). I was born and raised in Austin, Texas, but my family is originally from a little town outside of Austin called Lockhart, the BBQ capitol of Texas. I am the second to youngest of 5 biological siblings, but I have 2 half sisters.

I started PA school on May 19th, 2014 at UT Southwestern in Dallas, Texas. I previously worked for St. David's Medical Center in Austin, Texas while attending the University of Texas at Austin. While there, I worked on attaining my bachelor of science in biomedical engineering. During undergrad, I also did lots of volunteer work for many organizations on and off-campus, including working for Austin State Hospital. While at ASH, I worked for the education rehabilitation facility where we would hold focus groups for patients that used drugs and developed mental disorders (such as schizophrenia) or had mental disorders and used drugs to cope with them. I learned a lot about mental health and the lack of resources in the state of Texas. It fostered a desire for me to want to pursue mental health, such as psychiatry or neurology, which is why I eventually found myself at St. David's.
While there, I was a patient care technician, which is similar to a CNA, but we are trained on-the-job, and is how I originally was introduced to the physician assistant profession. After working in the ICU and Neurology units collectively for about 2.5 years, I decided to shadow a PA & physician at Scott & White (now Baylor Scott & White) Hospital in general surgery. I was able to observe the differences between the physician and PA, but also see their team-work and how their relationship meshed so well together so that they could get work accomplished much quicker and efficiently. I also was able to see them both act together in clinic and in surgery, so it was a really nice dynamic that I'm not sure most people get to see anywhere else. Before entering PA school I also was a private mathematics tutor for many years, and eventually I worked for Sylvan Learning Center the fall before PA school started. I had always wanted to teach children and I knew it would be my one opportunity to do so. Since this was a short-lived experience, I took a job with an artificial cervical disc company. While there I created presentations for physicians to present at conferences and wrote papers over the data we were receiving from the patients using our products. I learned a lot about degenerative disc disease and arthroplasty, and sparked an interest in neurosurgery.

I attended my dream school, UT Southwestern Medical Center, about 4 years later. I am so happy I made the decision to come to Dallas. I love Dallas and I love working with children. I graduated in December of 2016 and accepted a position at Children's Health. I have worked at Children's Medical Center Dallas since January of 2017 in pediatric epilepsy.

This is my personal blog, and I will post about topics that I have read about in previous and current issues of PA professional, JAAPA, JPAE, and other articles I find online that may be helpful to Pre-PA students, current PA students, and practicing PA's. I hope you enjoy and let me know if you have any comments or questions for me.