The
Medical Society wishes to express strong opposition to the proposed changes to
the regulations of the Executive Office of Health and Human Services, 101 CMR
317.00, including the elimination of the HN Modifier, which eliminates the
ability of a physician to be properly reimbursed for the care provided by a
properly supervised physician assistant (PA). These regulations would create
disparate reimbursement levels and billing requirements among different allied
health professionals—namely PAs and certified nurse practitioners (CNPs)—who
have been considered to provide equally valuable care. The Medical Society
believes that these changes could have detrimental impacts on the quality of
health care provided in team-based care models, and could significantly affect
access to care for MassHealth beneficiaries.
The
regulations of the Board of Registration of Physician Assistants requires that
“all professional activities of a physician assistant must be supervised by a
supervising physician.” Physician assistants must prescribe pursuant to
guidelines mutually developed with a physician. Physicians employing physician
assistants are legally responsible for the acts of the physicians.
In
light of these statutorily mandated supervisory functions, and best practices
of the physician and PA communities, the Medical Society strongly opposes the
elimination of the modifier that previously allowed physicians to bill on
behalf of the physician assistant. This modifier allows physicians to bill at
100% of the physician fee schedule, rather than at 85%, as is otherwise
dictated per section 317.03(5) of these regulations.
The
Medical Society has long supported physician-led team based health care that
utilizes many different health care professionals, including advanced practice
registered nurses (APRNs) and physician assistants, to optimize access to and
quality of medical care- ideals that are important to the MassHealth program.
Incident-to billing, that is, the practice of billing select services by health
care teams members such as physician assistants under the physician’s NPI using
billing modifiers, appropriately reflects the complexity of team-based care.
While physician assistants may provide the bulk of the care after initial
service by the physician, the physician retains a supervisory and consultative
function to the clinician and to the patient. These are tangible, important
functions to ensure optimal quality of care for patients. These tasks carried
out by the physicians include in-person consultation with the clinician and/or
the patient, retrospective chart review or case discussion, and other quality
assurance activities. These practices by physicians are particularly important
to ensuring quality of care of pediatric patients or patients with complex
medical issues- two key patient populations for the MassHealth program.
Physicians also spend time assisting in the medication management of advanced
practice nurses in MA, especially since PAs are statutorily required to
prescribe pursuant to guidelines mutually developed with a physician. It is
essential that incident-to billing and the HN modifier, which is designed to
capture the entire team-based care episode, be retained to promote these best
practices. Additionally, incident-to billing is not reserved solely for the
office setting: physicians often utilize the bill code for shared office visits
or for instances in which a physician provides care in an emergency room.
The
proposed changes are further troubling as they would part from Medicare’s
longstanding and widely recognized recognition of incident-to billing. With the
ever-complicating nature of billing and coding, this only further perpetuates
the problem of inconsistent policies between public payers.
MassHealth
funding levels already create strain on many physician practices. Eliminating
incident-to billing would further exacerbate the reimbursement issue: not only
would physicians be under-reimbursed for the level of care that they directly
provide and bill for, but they would also no longer be compensated for all of
the supervisory and consultative tasks that they undertake when care is
provided by advanced practice nurses or physicians assistants. This 15%
reduction that would occur if indecent-to billing is prohibited could reduce
the supervisory or consultative safeguards that many physicians implement in
their offices, or could further discourage participation as MassHealth providers.
Furthermore, this could undermine the fiscal soundness of physician practices
which could lead to access to care issues.
The
Medical Society respectfully requests the retention of the HN modifier to allow
for proper reimbursement of team-based care teams comprised of physician
assistants and supervising physicians.
As for
the remainder of the fee schedule, the Medical Society urges MassHealth to find
ways to provide reasonable fee increases to at least account for the
inflationary increases in costs of running a medical practice. Each year that
passes, as cost-of-living and cost of running a medical practice increases,
stagnant fee schedules widen the gap between commercial payments and those of
public payers such as MassHealth. The Medical Society therefore strongly
supports a fee schedule that adequate reimburses physicians for their services
so that MassHealth participation promotes practice sustainability, and to
ensure a robust provider network for MassHealth beneficiaries.
