Health Services Associates, Inc. Ron L. Nelson, PA

1. Health Services Associates, Inc.Ron L. Nelson, PA 2 East Main Street Fremont, Michigan 49412 Ph: 231-924-0244 Fx: 231-924-4882 Email: nelson@hsagroup.net www.hsagroup.net “Promoting Access to Health Care”

2. Objectives • Review billing requirements for billing PA/NP provided service • Review models to calculate value, economic and improved efficiency • Demonstrate current productivity and compensation data regarding NP/PA • Discuss strategies to enhance revenue utilizing NP/PA/Physician Teams

3. Understanding the Value of Non-Physician Providers

4. Benefits of Team Practice • Integration not fragmentation. • Emphasis on continuity of care. • Across visit, providers, illness episode, time. • Reject independent practice & separate reimburse. • Exercise autonomy in medical decision making.

5. Introduction • Coverage of services of non-physicians has evolved over the last decade. • Many different interpretations and changes have caused confusion. • Coverage in different settings. • Definition of supervision—collaboration confusing. • Inconsistent application of “incident to” provisions.

6. Differences exist between PAs, NPs, and CNS that cause confusion. • CMS offices are confused. • Carriers confused.

7. Health Reform proposes to cover an additional 30 million • Work force projections indicate deficit in available physicians • Physicians/PA/NP- moving towards specialty

8. Physician Assistant (PA) Definition: • Has graduated from a physician assistant educational program that is accredited by ARC-PA. • Has passed the national certification examination that is certified by the NCCPA • Licensed (authorized) by the state to practice as physician assistant

9. Physician Assistant Covered Services • Physician services if furnished by a MD/DO. • Performed by a person who meets the definition of a PA. • Authorized by state law. • Performed under supervision of a physician (supervised is defined by state law). • Not otherwise precluded from coverage.

10. Nurse Practitioner (NP/APN) Definition: • Registered professional nurse currently licensed to practice in the state.

11. Nurse Practitioner Meet one of the following: • Be certified as a nurse practitioner by the ANCC or other recognized national certifying bodies that have established standards for NPs. • Be a registered professional nurse who is authorized by the state in which the services are furnished to practice as a nurse practitioner in accordance with state law.

12. Nurse Practitioner Covered Services: • Physician services if furnished by a MD/DO. • Performed by a person who meets the definition of a NP. • Authorized by state law. • They are performed in collaboration with a MD/DO. • They are not otherwise precluded from coverage.

13. Medicare Enrollment • 855 Form • Most forms processed within 60 days • Section J is specific to PA’s. • All NPP’s should be enrolled

14. “Incident To” • An integral, although incidental, part of physician’s professional service. • Commonly rendered without charge or included in the physician’s bill. • Of a type that are commonly furnished in the physician’s offices or clinics. • Furnished under physician’s direct personal supervision. • Furnished by the physician or an individual who qualifies as an employee of the physician.

15. “Incident To” • Recent indications that carriers have latitude to interpret definition of supervision “Incident To”

16. Medicare Update PA/NP’s can bill: • All E/M codes • Consultations • Mental Health Services • Fracture Care

17. Shared Hospital Visit • When a physician and a PA/NP treat the same Medicare patient on the same day the work of both can be combined and billed under the physician at 100% of the fee schedule. • It doesn’t matter what amount of work the physician provides as long as the physician provides a face-to-face portion of the E/M service.

18. Shared Hospital Visit • Only for evaluation and management services or consults (not procedures). • PA and physician must work for the same employer/entity. • Medical record should reflect the service provided by the PA/NP and the physician.

19. Issues • Who Bills – Medicare • How do we maximize billable revenue for PA/Physician teams. • Does Medicare have restriction on codes. • How to maximize utilization of PA/MD teams and remain compliant. • Teaching Hospitals – What are documentation requirements?

20. Assignment • Required to accept assignment when billing as NPP services. • When billing “incident to” it is physician’s choice.

21. To understand value, we also need to understand costs… • Physical Plant • Support Staff • Patient Acceptance • Evaluation of Cost vs. Revenue

22. What information do I need? • Practice Revenue vs. Expenses • Managed Care Market • Current Models in Community • Availability of Workforce • Physician Attitudes

23. Compensation • What do we need to consider in compensation strategies for a PA/NP?

24. Compensation Encourages optimum productivity while enabling the professional the necessary personal and professional job satisfaction.

25. Contract Terms • Compensation • Terms—Length • Supervision / Collaboration • Incentives • Definition of Expected Duties / Call

26. Compensation Sources: • National Data • MGMA • AAPA • Private Databases

27. Compensation Salary—Median Income Source: MGMA Physician Compensation and Production Survey 2009 Report Based on 2008 Data.

28. Cost-Effectiveness Median ratio of compensation to gross charges: PANP Median .25 .30 “For those services a PA or NP can handle just as effectively as a physician, a mid-level provider is a less costly investment for the group practice.” Compensation = RATIO Gross Charges Sources: MGMA Physician Compensation and Production Survey 2009 Report Based on 2008 Data.

29. Compensation by Years in Specialty Source: MGMA Physician Compensation and Production Survey 2009 Report Based on 2008 Data.

30. Compensation by Gender (Median) 30% Survey Reported: 70% Source: MGMA Physician Compensation and Production Survey 2009 Report Based on 2008 Data.

31. PA Hourly Wage vs. Annual Wage Us Labor Statistics

32. PA SalariesAverage Salaries by State PA Advance, 2009

33. Average PA Salaries by Specialty (PA Advance, 2009)

34. Mean Number of Visits per Week per PA by Specialty AAPA, 2009

35. Gross Charges (TC Excluded) Source: MGMA Physician Compensation and Production Survey 2009 Report Based on 2008 Data.

36. Collections for Professional Charges (TC Excluded) Source: MGMA Physician Compensation and Production Survey 2009 Report Based on 2008 Data.

37. Charges vs. Collection Median Median Gross Charges MGMA Specialty Collection Source: MGMA Physician Compensation and Production Survey 2009 Report Based on 2008 Data.

38. Collection Ratios (TC Excluded) Collections = Collection Ratio Gross Charges Source: MGMA Physician Compensation and Production Survey 2009 Report Based on 2008 Data.

39. What Other Value Does the PA/NP Bring to the Practice?

40. Quality Indicators • Patient Satisfaction • Less Waiting Time • Improved Profiling • Decrease ER Utilization

41. Patient satisfaction will become one of the most important quality indicators.

42. Productivity—Ambulatory Encounters Median Source: MGMA Physician Compensation and Production Survey 2009 Report Based on 2008 Data.

43. Work RVUs CMS RBRVS Method (Median) Sources: MGMA 2009 Physician Compensation and Production Survey

44. Work RVU by SpecialtyCMS RBRVS Method (Median) Sources: MGMA 2009 Physician Compensation and Production Survey

45. NP/PA/Physician Productivity • Billable Revenue • Bundled Revenue • Physician Revenue • How do we calculate productivity?

46. Employment-Surgery • Example: A surgeon employs a PA who first assists in the OR. The PA then does daily post-op rounds, changes dressings, pulls drains, writes orders, dictates discharge summaries, and writes discharge prescriptions. • Can the surgeon’s practice bill for these services provided by the PA? • PA overhead/bottom line/bean counting

47. Employment-Surgery Medicare fee breakdown: • 11% for pre-op work (H&P) • 76% for intra-operative (surgical procedure) • 13% for post-op care (10/90 days) • *24% of global payment is for non-OR services

48. Productivity • Example: Total knee $1769 Global • Pre-op $ 194.59 • Intra-op $ 1344.44 (surgeon) • Post-op $ 229.97 • plus • First Assist $ 240.58 • If PA performs pre- and post-op work and First Assists, the measure of PA “value” would be $665.14 for the case.

49. Productivity • If PA didn’t perform pre- and post-op work, the physician would have to. • If PA’s deliver non-billable services, the surgeon/physician is able to provide new, revenue generating services such as E/M in the office or more surgery.

50. Physician/PA Productivity ASSUMPTIONS: Calculations 250 average TSA’s resulting in procedures/day x 20 working days. Calculations 12 procedures/week x $35/procedure. Calculations 440 preoperative H&P x $125/each, currently bundled in Surgical fee. Calculations 880 post operative visits x $45/each, currently bundled in Surgical fee. Calculations 3 additional consults/week @ $1500 x 48. Calculations 3 additional consults/week @ $150 x 48. ADDITIONAL ASSUMPTIONS: Conservative estimates based on gross billings in a surgical practice. Physician Assistant spends majority of time in a hospital setting. Physician increased patient time. However, may also allow for more physician time off which would reduce total numbers. Physician Assistant spends 57% of FTE on direct clinical services (31%billiable/26% reduction). Allow 23% of FTE increased time for productivity or other activities for Physician.