Pennsylvania PAs made Rendering Providers under Medicaid
Beginning September 1, 2016, Physician Assistants in Pennsylvania were enrolled as participating providers who could order, refer or prescribe items for Medical Assistance beneficiaries. The PSPA has been trying to change our status from participating providers to enrolled rendering providers since that time. On January 7th, 2022, The Pennsylvania Department of Human Services published in the Pennsylvania Bulletin that this monumental change has occurred. The language and the steps that need to be taken by PAs and their employers can be found at this link: https://www.dhs.pa.gov/docs/Publications/Documents/FORMS%20AND%20PUBS%20OMAP/MAB2022010701.pdf
History:
Pennsylvania PAs were hidden providers under the state’s Medicaid program as claims for PA services were attributed to their supervising physician. This system prevented patients, regulators, employers, and legislators from knowing which healthcare professional was accountable for a patient’s care. The issue of appropriate enrollment of PAs was about accountability and transparency. Because Pennsylvania PAs are hidden providers, inaccurate data was delivered to policymakers on workforce and network adequacy considerations. This has lead to an inefficient allocation of taxpayer resources.
Impact of this change
There are now 48 states across the country that enroll physician assistants in Medicaid programs as rendering providers, authorizing them to use their own provider number when claims are submitted to Medicaid to identify who rendered the service. PAs will be recognized as enrolled rendering providers under Pennsylvania’s Medicaid program, allowing services provided by PAs to be submitted with the PA’s name and NPI included on the claim form indicating that he or she rendered the service. Enrollment of PAs as rendering providers under Medicaid will lead to the identification of PAs in provider directories. This clear identification of health professionals locally delivering care will make it easier for patients, especially those in underserved communities, to find care options, particularly in a time of physician shortage.
The enrollment of PAs as rendering providers does not increase costs for the state Medicaid program or duplicate services. PAs are currently providing said services but submitting claims under the physician’s provider number. Payment would continue to go to the employer.
This status change is a huge win for PSPA and PAs of Pennsylvania. Much thanks goes to the PSPA Board of Directors and the Governmental Affairs team.
Medicare
Medicare is a government-administered program providing health insurance to 43 million Americans. The Centers for Medicare and Medicaid Services (CMS) implements laws and establishes policies affecting Medicare and contracts with health care professionals to process Medicare claims.
Medicare rules require that services provided by physician assistants (PAs) be reimbursed at 85 percent of the physician fee schedule unless in specific billing exceptions (“incident to” and “shared visits billing”) . A PA must enroll in the Medicare program by submitting the 855I form, and use his or her National Provider Identifier (NPI) number to alert the carrier to implement the 15 percent discount.