According to recently clarified guidelines by Indiana Medicaid, all physician assistants (PAs) must now enroll as Indiana Health Coverage Providers and can no longer be billed under a supervising physician’s NPI. This change, which brings billing for PAs into alignment with billing for other Mid-Level, or Non-Physician Providers (NPP), also reduces reimbursement for PA services to 75 percent of the Medicaid allowed amount.
The policy change allowing PAs to be fully enrolled in Indiana Medicaid was originally announced back in June 2017. At that time, Indiana Medicaid communicated to providers that this change was intended for PAs in a primary practice setting only. Based on that information, it appeared that hospital-based PAs were not required to enroll and their services could continue to be billed under the supervising physician’s NPI with the appropriate modifier (HN or HO) indicating the PA’s level of education.
However, on June 7, 2018, the guidelines were re-issued requiring all PAs to enroll with Indiana Medicaid, and all services to be billed under the PA, not the supervising physician, with a 75 percent reimbursement, except in specific circumstances. The June 7 guidance had an effective date of August 1, 2018, dates of service for the change in billing practice. However, on June 19, 2018, IHCP corrected the effective date to August 1, 2017, dates of service. The implications of that change were not explained, though PAs should take immediate action to enroll with Indiana Medicaid (type 10, specialty 100) to avoid any interruption in billing.
This policy change clearly has revenue implications for Indiana emergency medicine groups who utilize PAs. However, when both the physician and the NPP provide any face-to-face portion of an evaluation and management (E/M) encounter, the service may continue to be billed under the physician’s NPI based on split/shared visit rules. According to the Centers for Medicare and Medicaid Services’ (CMS), Split/Shared E/M Services for the emergency department are explained as follows:
When a hospital inpatient/hospital outpatient (on campus-outpatient hospital or off campus outpatient hospital) or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician’s or the NPP’s NPI. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP’s NPI. Payment will be made at the appropriate physician fee schedule rate based on the NPI entered on the claim. (from page 39 of the Medicare Claims Processing Manual: Chapter 12 – Physicians/Nonphysician Practitioners)
Other exceptions to the new policy, highlighted in the IHCP Medical Practitioner Reimbursement guide, include the following:
- Physician assistant services for “assistant surgery” should be billed with the physician assistant’s NPI as well as the AS modifier; reimbursement for these services is paid at 20% of the already reduced rate (20% of 75%).
- Physician assistant services rendered through an FQHC/RHC should be billed using the physician assistant’s NPI as the rendering provider; reimbursement for these services is based on provider specific encounter methodology.
Prior to this new guidance from Indiana Medicaid, CIPROMS enrolled PAs as Ordering, Prescribing, or Referring (OPR) providers. Now, those PAs must be disenrolled as OPR providers and re-enrolled with the full status recently allowed by Indiana Medicaid. For this new enrollment status, PAs will need to provide the following:
- IHCP Provider Application and Maintenance Form
- Provider Agreement
- Federal W-9 form
- Clinical Laboratory Improvement Amendments (CLIA) certificate, if applicable
- Proof of Medicare participation, if enrolled in Medicare
- Copy of current license from Indiana Professional License Agency (IPLA)
According to Andrea Halpern Bryan, CIPROMS VP of Client Relations, CIPROMS reached out to IHCP and the Indiana Family and Social Services Administration to address the fact that this policy was delivered on short notice and not clearly outlined. Also, there has been mixed communications and instructions provided by IHCP and the various Medicaid Managed Care entities (MCEs) regarding this policy.
“CIPROMS is still awaiting clarification from some of the MCEs about required enrollment. Several have answered but their policies have been inconsistent and subject to change,” Bryan said.
For more information about this policy, please refer to the IHCP Medical Practitioner Reimbursement guide. CIPROMS clients who are PAs or who lead groups utilizing PAs should be on the lookout for communication from their account representative and/or their provider enrollment representative about the new Indiana Medicaid enrollment requirements.
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