Contents Page. Introduction 2. Policy and Regulations; Scope of Practice AMA Policy 2 Federal Regulations 2 Washington State Regulations 2

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1 2001 Sixth Avenue 1800 Cooper Point Road SW Suite 2700 Building 7, Suite A Seattle, Washington Olympia, Washington Fax Fax wsma@wsma.org Physician Assistants in Washington State: Physician Practices and the Care Team Model September 2014 Note: By late 2014, the Washington State Department of Health is expected to introduce revised rules that regulate the activities of Physician Assistants in Washington. Once those rules have been finalized, this WSMA guidance document will be revised to reflect and communicate those changes. Contents Page Introduction 2 Policy and Regulations; Scope of Practice AMA Policy 2 Federal Regulations 2 Washington State Regulations 2 Clinical Competence, Qualifications and Credentials 3 Supervision, Credentialing, Prescribing, Professional Liability Insurance 3-4 Assessing Clinical Competence, Qualifications and Credentials 4 Hospital Privileges 5-6 Recruitment and Hiring 6-9 Appendices A AMA Policy 10 B National Commission on Certification of Physician Assistants (NCCPA) C Health Insurance: Billing D Washington Physicians Guide to Health Law: Physician Assistants E Washington Physicians Guide to Health Law: Osteopathic Physician Assistants F Washington Physicians Guide to Health Law: Nurse Practitioners (Note: this material is included to provide contrast between PAs and ARNPs.) Physician Assistants in Washington State Page 1

2 Introduction Physicians in Washington state have decades of positive experience in working with Physician Assistants (PAs) in their practices. In the late 1960s, Dr. Richard Smith enrolled the first class of former military medics and corpsmen into the new MEDEX program at the University of Washington in Seattle ( ). Numerous studies indicate there will be a growing shortage of physicians, and that treatment and payment models, including accountable care organizations (ACOs) and patient centered medical homes, will place greater demands on Washington s care delivery system. This guidance document offers an overview of strategies and questions for physicians, practice administrators and physician assistants to consider in adding a Physician Assistant to a practice. Disclaimer Nothing in the following presentations or materials is intended to encourage any joint action by individuals or business entities that would violate any state or federal laws. The Washington State Medical Association provides this information with the express understanding that the information is of a general character. You should not rely solely upon this information when dealing with business operational matters specific to your practice, and you should seek professional and legal advice from retained consultants and legal counsel as is appropriate. The WSMA gratefully acknowledges resources drawn from the Washington Academy of Physician Assistants (WAPA), the American Academy of Physician Assistants (AAPA) and the National Commission on Certification of Physician Assistants (NCCPA). Policy and Regulations; Scope of Practice The AMA Code of Medical Ethics, Opinion Allied Health Professionals, establishes general principles for physicians in their relationships with Physician Assistants and other allied health professionals ( See Appendix A ). The AMA also has policy on Physician-Led Health Care Teams. The AMA defines teambased health care as the provision of health care services by a physician-led team of at least two health care practitioners who work collaboratively with each other and the patient and family to accomplish shared goals within and across settings to achieve coordinated, high-quality, patientcentered care. [ H The Structure and Function of Interprofessional Health Care Teams ] Federal regulations, relating to prescribing, explain: Pursuant to Title 21, Code of Federal Regulations, Section (b28), the term midlevel practitioner means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice. Examples of mid-level practitioners include, but are not limited to, health care providers such as nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists and physician assistants who are authorized to dispense controlled substances by the state in which they practice. [ US DOJ / DEA website ]. Physician Assistants in Washington State Page 2

3 In Washington state, the Revised Code of Washington (RCW) Chapter 18.71A regulates the practice of Physician Assistants ( ). RCW 18.71A.050 Physician's liability, responsibility explains: No physician who supervises a licensed physician assistant in accordance with and within the terms of any permission granted by the commission is considered as aiding and abetting an unlicensed person to practice medicine. The supervising physician and physician assistant shall retain professional and personal responsibility for any act which constitutes the practice of medicine as defined in RCW when performed by the physician assistant. RCW 18.71A.060 Limitations on health care services explains: No health care services may be performed under this chapter in any of the following areas: (1) The measurement of the powers or range of human vision, or the determination of the accommodation and refractive state of the human eye or the scope of its functions in general, or the fitting or adaptation of lenses or frames for the aid thereof. (2) The prescribing or directing the use of, or using, any optical device in connection with ocular exercises, visual training, vision training, or orthoptics. (3) The prescribing of contact lenses for, or the fitting or adaptation of contact lenses to, the human eye. (4) Nothing in this section shall preclude the performance of routine visual screening. (Note: sections regarding dentistry, dental hygiene, chiropractic and podiatric services are not included here for brevity.) Clinical Competence, Qualifications and Credentials The National Commission on Certification of Physician Assistants (NCCPA) develops Certificate of Added Qualifications (CAQ) programs that allow PAs to earn formal recognition of their specialty expertise - in cardiovascular and thoracic surgery, emergency medicine, nephrology, orthopaedic surgery and psychiatry ( See Appendix B ). Supervision, Credentialing, Prescribing, Professional Liability Insurance Supervising a Physician Assistant ( See Appendices D and E ) (Note: Washington law does not require that Physician Assistant notes or other clinical documents be co-signed by a physician. The law states that Physician Assistants may sign and attest to any document that might ordinarily be signed by a licensed physician, (WAC (2)). Regarding supervision, Washington state law requires that Physician Assistants practice medicine only under the supervision and control of a physician, (RCW 18.71A.020(2)(b)(ii)) and the Washington Administrative Code requires that the details of the practice arrangement between the Physician Assistant and the supervising physician be on file with the Medical Quality Assurance Commission.) Physician Assistants in Washington State Page 3

4 Credentialing The AMA Membership Department provides a "Physician Profile" service free for all AMA members ($29 for non-ama members). The content of AMA profiles are intended to assist with credentialing of Doctors of Medicine (MDs), Doctors of Osteopathic Medicine (DOs), and Physician Assistants (PAs) ( ). Prescribing Federal regulations, relating to prescribing, explain: Pursuant to Title 21, Code of Federal Regulations, Section (b28), the term midlevel practitioner means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice. Examples of mid-level practitioners include, but are not limited to, health care providers such as nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists and physician assistants who are authorized to dispense controlled substances by the state in which they practice. [ US DOJ / DEA website ]. For Washington state regulations on prescribing: ( See Appendices D and E ) Professional Liability ( Medical Malpractice ) Insurance (See Appendices D and E ) Assessing Clinical Competence Guide for regulators, hospitals, employers and third-party payers Physician assistants (PAs) are versatile members of the medical team, with broad, yet rigorous medical training. PAs practice in every medical and surgical specialty and every practice setting, providing a broad range of services that would otherwise be provided by physicians. They are graduates of accredited PA programs, licensed and nationally certified. PA education is a masters-level program modeled on physician education. Applicants must complete at least two years of college courses in basic and behavioral sciences as prerequisites. PA education programs average 27 months in length. The first year of PA school provides a broad grounding in medical principles and instruction in the classroom and lab. Year one consists of basic medical science courses, including anatomy, physiology, biochemistry, pharmacology, physical diagnosis, pathophysiology, microbiology, clinical laboratory sciences, behavioral sciences and medical ethics. In the second year, PA students receive hands-on clinical training through rotations that include family medicine, internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine and psychiatry. PA students complete on average more than 2,000 hours of supervised clinical practice prior to graduation. There are more than 181 PA programs accredited by the Accreditation Review Commission on Education for the Physician Assistant. Upon graduation from a physician assistant program, PAs must pass the Physician Assistant National Certifying Examination (PANCE), the initial certifying exam administered by National Commission on Certification of Physician Assistants. To maintain current certification, PAs must complete 100 hours of continuing medical education every two years and pass the NCCPA s Physician Assistant National Recertification Examination (PANRE) every six years. Physician Assistants in Washington State Page 4

5 NCCPA s Certification Maintenance requirements are scheduled to change in 20144, with enhanced CME requirements and re-examination extended to a 10-year cycle, to mirror the Maintenance of Certification requirements for physicians. While all states require initial certification for initial licensure, not all states require maintenance of current certification for licensure renewal. Credentialing PAs Organizations credential healthcare professionals to assure that patients receive high quality medical care. Hospitals, healthcare organizations, practices and third-party payers use varied systems for doing this. Many organizations adapt physician forms and criteria to create a parallel process for PAs. For PAs, primary sources include State licensing board to confirm that the applicant is properly licensed. Accredited PA program for graduation information National Commission on Certification of Physician Assistants (NCCPA) to confirm initial and ongoing national certification. Go to National Practitioner Data Bank (NPDB) for malpractice and adverse actions history. American Medical Association (AMA) Physician Profile Service offers PA credentials verification. For a nominal fee, credentialing professionals can confirm a PA s education program attendance and graduation dates, national certification number and status, current and historical state licensure information, and AAPA membership status. The Joint Commission has deemed that the information provided by the AMA service is equivalent to primary source information. Federation of State Medical Boards offers its Federation Credential Verification Service to PAs. Hospital Privileges Privileging PAs in Hospitals Because of the breadth and rigor of PA education programs, students graduate with skills that are fundamental and essential to every specialty a fund of medical knowledge, interpersonal and communication skills, patient care-including the ability to provide age appropriate patient assessment, evaluation and management, professionalism, practice-based learning and improvement, and systems-based practice.5,6 PAs providing care in the hospital must be privileged through the Medical Staff process whether they are employed by the hospital or by an outside practice. Core Privileges Some organizations identify core privileges that may be granted to any PA who meets the organization s criteria. Core privileges may vary depending upon the clinical department. They include, but are not limited to such things as performing histories and physicals; developing and implementing treatment plans; performing rounds; recording operative and procedure notes; recording progress notes; ordering and interpreting diagnostic laboratory tests and diagnostic imaging studies; ordering medications and writing prescriptions; managing fractures; suturing lacerations; performing corneal fluorescein exams and foreign body removal; providing anterior nasal packing for epistaxis; administering trigger point injections; incising and draining Physician Assistants in Washington State Page 5

6 abscesses; and performing discharge summaries. This listing of PA core privileges is not meant to be exhaustive. There could be other core privileges, depending on the institution and department. Specialty Privileges PA medical education is broad. PA students master clinical fundamentals that prepare them to practice with physicians in virtually every area of medicine and surgery. However, unlike physicians, PAs do not have specialty board exams. They specialize by virtue of the physicians with whom they work. When PAs are evaluated for specialty privileges, hospitals can verify their competence through a number of means: Attestation to the PA s competence by physicians and PA peers Hospital systems that track clinical activity Data collected for initiatives such as the Surgical Care Improvement Project (SCIP) or the Physician Quality Reporting System (PQRS) Requiring a certain percentage of continuing medical education credits specific to the specialty Requiring maintenance of pertinent certifications such as Basic Life Support, Advanced Cardiac Life Support, Advanced Trauma Life Support, Pediatric Advanced Life Support, etc. Certificates of completion from relevant clinical courses Use of simulation labs to assess cognitive and procedural competence Professional portfolio in which the PA documents procedures and patient care provided When a PA is a recent graduate or is changing specialties, it may be necessary to facilitate proctoring by a physician or senior PA until the PA requesting privileges can demonstrate competence. FPPE and OPPE Joint Commission accredited hospitals are required to include PAs in their focused professional practice evaluations (FPPE) and ongoing professional practice evaluations (OPPE), which are intended to help ensure the competence of providers. Data for the ongoing evaluation is acquired from periodic chart review, direct observation, procedures logs, peer review, monitoring of diagnostic and treatment techniques, and input from other individuals involved in the care of the same patients, including clinicians and administrators. Recruitment and Hiring The Washington Academy of Physician Assistants (WAPA - ) accepts Job Postings. To have your job announcement posted on the WAPA Job Bulletin, send an to WAPA satisfying these requirements: 1000 characters or less, a brief job description, a contact person, your preferred mechanism for the PA to send you their CV with cover letter ( , fax, hard copy). WAPA charges a $75.00 fee per position, to run for 90 days. If you have multiple positions to post, Linda at: LMK@wsma.org for a special rate. WAPA s postings are viewed by PAs in WA as well as those seeking to re-locate to Washington state. Physician Assistants in Washington State Page 6

7 Guide for New Physician Assistant Employers Deciding to Hire One of the most valuable attributes of the physician assistant (PA) profession is the flexibility in role and function of the PA within the dynamic model of the physician-pa team. PAs can provide versatile medical care in all settings and specialties because of their broad general medical education. Hiring a PA means gaining an extra set of skilled hands, eyes, and ears. PAs offer an array of benefits to practices and physicians, including higher revenues, improvements in patient satisfaction via accessible care, and more flexibility in the schedules of their employers. Knowing what your practice or institution needs is the first step in making the most of the physician-pa team. Where would your practice most benefit from this assistance? A thorough analysis of your current practice needs and your patient population is time well spent and will help you find the physician assistant who will be the perfect fit. Preparing to Hire Create a Job Description Begin by developing a detailed job description that reflects the needs of your practice. Be sure to involve the physician(s) who will be supervising the PA(s) and consider the supervisory style and specialties of your practice or institution. Do you seek a new graduate or a practiced veteran? Newly graduated physician assistants usually require close mentoring for the first few months of their employment; this is generally not the case with more experienced PAs. The job description should address the following issues: Will the PA see all patients, just followup patients, or all first time patients? Will they establish their own patient panel? Would you like the PA to make hospital rounds? Assist in surgery? Take call? Read Your State PA Practice Act Well in advance of hiring, familiarize yourself with your state PA practice act especially its provisions concerning supervision, prescribing, and delegation. A summary of PA regulations and contact information for all state medical boards is available at In addition, AAPA staff is ready to assist you with specific questions. Develop an Employment Package The American Academy of Physician Assistants (AAPA) can assist your practice as you devise a PA employment package. Visit the Academy s Web site for national data on PA salaries and benefits: Contracts are an essential element of the employment package. Contract negotiation lays the foundation for a fair and mutually beneficial professional relationship. The AAPA Web site features guidelines for creating contracts. Visit Understand PA Credentialing and Privileging Perform a thorough credentials check on the candidate. One excellent way to verify credentials is through the AMA Physician Profile Web site at Physician Assistants in Washington State Page 7

8 It provides all the necessary information on a PA s education; graduation; national certification status; current and historical state licensure information; and legal name, address, and date of birth. This information meets the Joint Commission s primary source requirements. During the hiring process, request the following from the PA: A copy of his or her current state license (with license #, DEA # if applicable, and expiration dates). A copy of current certification from the National Commission on Certification of Physician Assistants (NCCPA). PAs will get a certificate each time they recertify. This will have the NCCPA #, issue date, and expiration date. Letters of reference from previous employers and colleagues particularly peer recommendations and physician evaluations regarding the performance of specific responsibilities (i.e., surgical skills or other special skills). Documentation of CME records or additional training the PA has received, e.g., current ACLS, BLS, PALS, or other Certificates. A copy of any recent hospital privileges. If the PA has a log documenting specific procedures, request a copy. Inquire of the local hospital(s) about their policies regarding PA practice. Have PAs worked in the hospital before? Have they been privileged? If so, what are the procedures for privileging? How long will it take? Are there any physician cosignature requirements? Are competency measures used for any procedures the physician may want to delegate to the PA? What are the admission policies of the hospital? What are the policies on initial consultation in the hospital? Knowing the institution s policies on PA utilization in advance will save time and prevent surprises and frustration. Building a Successful Physician-PA Team Once the PA is on board, the PA and supervising physician(s) together should create a delegation agreement that flexibly defines the clinical partnership, taking into account the state laws and regulations. This is an opportunity to think through the ways in which you will work as a team. The physician and PA should discuss this document at least once a year and revise it as needed. AAPA s Professional Affairs staff can help with a template delegation agreement. Contact Jennifer Anne Hohman for more information at , ext. 3220; jhohman@aapa.org. Communication is the key to successful physician-pa teams; AAPA features guidance and resource materials to maximize it. Educate Staff and Patients The front office staff sets the tone for patient perception of providers. It is important that they understand that the PA is your medical partner. Educate staff to present the option of seeing a PA as a positive one. For example, they could explain that PAs allow for quicker appointments and that PA care is closely coordinated with the physicians. We suggest visiting the AAPA website for some information that is perfect for educating all members of the practice or institution, from front office staff to fellow physicians, about the education, qualifications, and unique role of PAs. Physician Assistants in Washington State Page 8

9 Having the physician personally introduce the PA to each patient at the first encounter is an effective way to build patient trust. Consider sending a letter to patients introducing the new PA, explaining the PA s background, and generally describing how the physician and PA will practice together. In addition, printed information about PAs should be available in the office for patients to read and take with them. AAPA produces brochures about PAs designed for waiting rooms. DEA Registration The Drug Enforcement Administration (DEA) has a registration category specifically for physician assistants and other so-called midlevel practitioners authorized by state law or regulation to prescribe controlled substances. For more information or to obtain a registration application, contact the DEA Registration Unit at 800/ Additional information on DEA registration can be found here. Pursuant to Title 21, Code of Federal Regulations, Section (b28), the term mid-level practitioner means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice. Examples of mid-level practitioners include, but are not limited to, health care providers such as nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists and physician assistants who are authorized to dispense controlled substances by the state in which they practice. Resources University of Washington MEDEX: Washington Academy of Physician Assistants (WAPA): American Academy of Physician Assistants (AAPA): Physician Assistants in Washington State Page 9

10 Appendix A AMA Code of Medical Ethics: Opinion Allied Health Professionals Physicians often practice in concert with allied health professionals such as, but not limited to, optometrists, nurse anesthetists, nurse midwives, and physician assistants in the course of delivering appropriate medical care to their patients. In doing so, physicians should be guided by the following principles: (1) It is ethical for a physician to work in consultation with or employ allied health professionals, as long as they are appropriately trained and duly licensed to perform the activities being requested. (2) Physicians have an ethical obligation to the patients for whom they are responsible to ensure that medical and surgical conditions are appropriately evaluated and treated. (3) Physicians may teach in recognized schools for the allied health professionals for the purpose of improving the quality of their education. The scope of teaching may embrace subjects which are within the legitimate scope of the allied health profession and which are designed to prepare students to engage in the practice of the profession within the limits prescribed by law. (4) It is inappropriate to substitute the services of an allied health professional for those of a physician when the allied health professional is not appropriately trained and duly licensed to provide the medical services being requested. (I, V, VII) Issued December Physician Assistants in Washington State Page 10

11 Appendix B National Commission on Certification of Physician Assistants National Commission on Certification of Physician Assistants (NCCPA) develops the concept of a "Certificate of Added Qualifications to meet the need of PAs for a credential in a specialty. ( ). In 1972, the National Board of Medical Examiners (NBME) and the AMA convened representatives from fourteen organizations, including the AAPA and PAEA, to discuss the need for establishing an independent certifying authority for the physician assistant profession. Three years later, the National Commission on Certification of Physician Assistants (NCCPA) was formed to fulfill that role. NCCPA is the only nationally recognized certifying body for physician assistants in the United States. Established as a not-for-profit organization in 1975, NCCPA is dedicated to assuring the public that certified physician assistants meet professional standards of knowledge and clinical skills. All U.S. states, the District of Columbia and the U.S. territories have decided to rely on NCCPA certification criteria for initial licensure or regulation of physician assistants. More than 100,000 physician assistants have been certified by NCCPA. To attain certification, PAs must graduate from an accredited PA program and pass the Physician Assistant National Certifying Exam (PANCE). PANCE is a multiple-choice test that comprises 300 questions that assess broad medical and surgical knowledge. After passing PANCE, PAs become NCCPA-certified, which entitles them to use the Physician Assistant-Certified (PA-C ) designation until the expiration of their first cycle (approximately two years). To maintain NCCPA certification and retain the right to use the PA-C designation, they must fulfill continuing medical education (CME) requirements every two years and pass a recertification exam every six to ten years. As the PA profession has evolved, so has NCCPA and the certification process. In 2002, NCCPA initiated an effort - ultimately joined by AAPA, PAEA, and the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) - to establish a profession-wide definition of PA competencies throughout a PA's career. That effort led to the publication of Competencies for the Physician Assistant Profession in Subsequently various NCCPA committees and staff have evaluated NCCPA's certification and certification maintenance processes to determine how those processes may be modified to assess, incorporate, or foster a broader range of the identified PA competencies. In 2011, the Board approved the addition of new directed CME requirements related to selfassessment and performance improvement activities and an extension of the recertification cycle from six to 10 years; PAs began transitioning to the new process in In 2009, the NCCPA Board of Directors brought to conclusion in some ways nearly 30 years of discussion when they provided the final approval for NCCPA to launch a Certificate of Added Qualifications (CAQ) program to recognize PAs experience and knowledge in certain specialty areas. Today CAQs are offered in cardiovascular/thoracic surgery, emergency medicine, hospital medicine, nephrology, orthopaedic surgery, pediatrics and psychiatry. To earn a CAQ, PAs must be NCCPA certified and have a valid state license (or comparable authorization to practice); meet specialty specific requirements related to CME, experience, and procedures and patient- Physician Assistants in Washington State Page 11

12 case management; and pass a specialty exam. The first specialty CAQ exams were administered in September NCCPA has earned accreditation from the National Commission for Certifying Agencies (NCCA). The NCCA is the accrediting arm of the Institute for Credentialing Excellence (ICE). Established in 1977 as a nonprofit organization, ICE is a leader in setting quality standards for certifying organizations. Physician Assistants in Washington State Page 12

13 Appendix C Health Insurance: Billing and Payment for Physician Assistants This guidance provides an overview of billing and payment issues for physician assistants, physicians and physician practice administrative staff in Washington State. It is highly recommended that you confirm the general information with specific health insurers with which the practice contracted to ensure compliance with specific policies and procedures. Disclaimer Nothing in the following presentations or materials is intended to encourage any joint action by individuals or business entities that would violate any state or federal laws. The Washington State Medical Association provides this information with the express understanding that the information is of a general character. You should not rely solely upon this information when dealing with business operational matters specific to your practice, and you should seek professional and legal advice from retained consultants and legal counsel as is appropriate. Enrollment/Credentialing The Medicare and Medicaid programs allow Physician Assistants (PAs) to credential directly with the program. A PA is allowed to submit claims to the Medicare program in two different ways that will be addressed later in this guidance. Nearly all commercial health insurers provide insurance benefits and payment for medical and surgical services provided by PAs. However, some insurers do not allow PAs to credential directly with the health plan. Rather, these insurers typically approach billing for non-physician practitioners one of two ways: Either the PA must enroll directly with the insurer as a provider and have the practice bill under its own National Provider Identifier (NPI) and the group tax ID, or The PA is not enrolled them and the practice bills for services under the supervising physician s name and NPI. It is important to distinguish between an insurer that does not cover services provided PAs and nurse practitioners (NPs) from an insurer that does not permit the PA or NP to enroll as a provider. Although many private insurers do not separately credential PAs or issue provider numbers, PAs are generally covered for most services they provide. It is the responsibility of the PA and their practice to be aware and adhere to each insurer s payment policy and claims submission requirements. Questions to ask Health Insurers regarding Physician Assistants Health insurers are able to set their own policies for credentialing non-physician practitioners (NPPs) and reimbursement for their services. Some insurers credential NPPs and allow their services to be billed under an NPP s provider number. Other insurers do not allow this and instead instruct practices to bill for services provided by NPPs as if the physician had provided them, using the physician's name and provider number on the claim. The Medicare program refers to this arrangement as incident-to billing and has specific rules that apply, which are explained below. Physician Assistants in Washington State Page 13

14 Health insurers that allow this type of billing may do so with fewer restrictions than Medicare. Unfortunately, this approach requires that the PA and practice staff determine the policy of each health insurer with which it contracts. Here are some key questions to ask: Do you credential non-physician providers? Do you include them in your provider listing and allow patients to select them as primary care providers? Do you require that submitted claims use the NPP's name and provider number, or the physician's name and provider number? Do you require any specific level of supervision or protocol? If we bill for the services of the NPP using the physician's provider number, and the patient's usual physician is not in the office, should we bill under the usual physician's name or the name of a physician who is in the office? What is your reimbursement rate for NPP services? Washington State Health Insurers Policies regarding Physician Assistants Most insurers in Washington State allow Physician Assistants to credential directly. However, they also can have policies that restrict payment to a percentage - typically 85 percent - of the physician fee schedule. It is highly recommended that the practice contact each health insurer with which it contracts to determine their specific policy. Claim Submission for Physician Assistants Services Once you have determined if the PA can credential directly with the insurer, determine how to properly submit insurance claims (bill) for the PA s services. Under Medicare, practices are allowed to submit claims under the PA s or NP s name and NPI number for those PAs that are W-2 employees, leased employees, or independent contractors. In some cases, the PA s services can be billed incident to the physician. In these cases, the practice bills the PA s service under the physician s name and NPI number. Services provided by independent contractor NPs or PAs cannot be billed incident to the physician. The manner in which the practice bills the Medicare program will determine the level of reimbursement received. The Medicare program pays the PA s employer for medical and surgical services provided by the PA in all settings at 85 percent of the physician s fee schedule. According to Medicare s guidelines, these settings include hospitals (inpatient, outpatient, operating room, and emergency departments), nursing facilities, offices, clinics, the patient s home, and first assisting at surgery. Services provided in physician practices may be billed under Medicare s incident-to provision. This provision allows payment at 100 percent of the physician fee schedule if the rules for incident to are followed. The Incident to provisions require that services must be part of the patient s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. The physician does not have to be physically present in the patient s treatment room while the services are provided by a PA. However, the physician must provide direct supervision, that is, the physician must be present in the office suite to render assistance, if necessary. Physician Assistants in Washington State Page 14

15 The patient record should document the essential requirements for incident to service. More specifically, these incident to services must meet all of the following conditions: An integral part of the patient s treatment course; Commonly rendered without charge (included in the physician s bills) Of a type commonly furnished in a physician s office or clinic (not in an institutional setting); and An expense to the practice. Examples of qualifying incident to services include cardiac rehabilitation, providing non-selfadministrable drugs and other biologicals, and supplies usually furnished by the physician in the course of performing his/her services, e.g., gauze, ointments, bandages, and oxygen. Medicare program rules also require that physicians maintain medical oversight of all patients and that they demonstrate ongoing involvement in patient care. This involvement can include personally treating the patient on a subsequent visit to the practice or reviewing the patient s chart with the PA following a PA-provided visit. In the hospital setting, PAs and physicians can follow Medicare shared visit rules and are thereby able to combine on one claim the services each delivers to the same patient on the same calendar day. For commercial health insurers, this issue is slightly more complicated. In some cases, the insurer will require that the practice bill all services rendered by the PA under the physician s name and NPI. However, many commercial health insurers do not refer to this as incident to and they do not impose the same on-site supervision and initial visit restrictions imposed by Medicare. In either case, commercial health insurers and Medicare defer to relevant state law for supervision and scope of practice requirements. It is important to check with each health insurer to determine the specific billing requirements for services provided by a PA or NP. Defining supervision To satisfy the Medicare program requirements, the PA must work with a physician supervisor who is primarily responsible for the overall direction and management of the PA s professional activities and for ensuring that the services provided are medically appropriate. The physician supervisor need not be present when the PA furnishes a service, unless state law provides otherwise. If the physician supervisor is not present, he or she must be immediately available to the PA for telephone consultation. Under Washington State law, a PA shall practice medicine only under the supervision and control of a licensed physician, but such supervision shall not be construed to necessarily require the personal presence of the supervising physician at the place where services are rendered. Also under Washington State law a physician may enter into delegation agreements with five physician assistants, but may petition the commission for a waiver of this limit. However, no physician may have under his or her supervision: (a) More than three physician assistants who are working in remote sites; or (b) more physician assistants than the physician can adequately supervise. This is important because the supervising physician and PA shall retain professional Physician Assistants in Washington State Page 15

16 and personal responsibility for any act performed by the PA which constitutes the practice of medicine. Chart Requirements: Co-Signature Another important aspect of Washington State law is that PAs and supervising physician s shall ensure that adequate supervision and review of the work of the PAs is provided. The PA and supervising physician shall ensure that all patient care measures are documented in written form by PA. Every written entry shall be reviewed and countersigned by supervising physician within 2 working days unless a different time period is authorized by commission. (No chart cosignature requirement for certified PAs.) Billing Risks In the US Department of Health and Human Services (HHS), Office of Inspector General s (OIG) Work Plan, the government continues to scrutinize the billing activities of non-physician providers to determine whether the billing error rate is higher for "incident to" services than for other services billed. When treating Medicare patients, there are financial rewards for increasing the use of "incident to" billing for non-physician providers who are an integral part of a medical practice. It is critically important that the billing strictly follow the incident to guidelines, as if those guidelines are not met, then PAs will be required to bill under their provider numbers and receive the lower reimbursement rate. Here are some tips to keep in mind when billing incident to services: Be sure to alert patients that services will be billed as physician services when the patient did not see the physician. Patients may inaccurately believe that the practice is trying to cheat the government. Let patients know why the billing is being done this way. "Incident to" is not an appropriate billing method for new physicians who have not yet been credentialed. If the physician is working with 1 or 2 non-physicians per day, every day, and all the billing is being submitted incident to the physician's billing data could raise a red flag with the OIG. The high number of relative value units billed or high amount of charges billed may trigger further review or an audit by the insurer. Claims filed under a physician s name and identification member are typically benchmarked by insurers on a regular basis, looking for those providers who appear to be billing for services that in aggregate would take more than a typical work day to provide. Physician Assistants in Washington State Page 16

17 Appendix D Physician Assistants WSMA: Washington Physicians Guide to Health Law What is a physician assistant (PA)? A PA is a health care provider who is licensed by the Medical Quality Assurance Commission (MQAC) to practice medicine to a limited extent only under the supervision and control of a physician and who is academically and clinically prepared to provide health care services and perform diagnostic, therapeutic, preventative, and health maintenance services. All PAs must wear identification or a badge identifying him or herself as a PA at all times when meeting or treating patients. What is the difference between a physician assistant (PA) and a certified physician assistant (PA-C)? A certified physician assistant (PA-C) is an individual who has successfully completed an accredited and approved physician assistant program and has passed the initial national boards examination. A physician assistant (PA) is an individual who either: Successfully completed an accredited and approved physician assistant program, is eligible for the national boards examination, and was licensed in Washington State prior to July 1, 1999; Qualified based on work experience and education and was licensed prior to July 1, 1989; Graduated from an international medical school and was licensed prior to July 1, 1989; or, Holds an interim permit. Effective July 1, 1999, an individual applying for a license as a physician assistant must have graduated from an accredited and approved physician assistant program and must be certified by successful completion of the national board examinations. Applicants for an interim permit will have one year from issuance of the interim permit to successfully complete the examination. May physician assistants sign documents ordinarily signed by a licensed physician? Yes. Both a PA and a PA-C may sign and attest to any document that might ordinarily be signed by a physician, including (but not limited to) birth and death certificates. Can military experience be used to become licensed as a PA in Washington? Yes. An applicant for a license as a PA who has military training or experience satisfies the training or experience requirements to become licensed as a PA unless the Medical Quality Assurance Commission determines that the military training or experience is not substantially equivalent to the standards of this state. What must a physician do to utilize a PA in the physician s practice? A physician who wishes to use a licensed PA must obtain approval from the MQAC. Before commencing practice, a licensed PA must apply to the MQAC for permission to be employed or supervised by a physician or physician group. The physician or physician group and the licensed PA must jointly submit to the MQAC a practice arrangement plan which delineates the manner and extent to which the PA will practice and be supervised. A new practice plan must be Physician Assistants in Washington State Page 17

18 submitted if a PA who is currently credentialed desires to become associated with another physician. A licensed PA may practice medicine only with the MQAC s approval of the practice arrangement plan and only to the extent permitted by the MQAC. A licensed PA who has not received approval of the practice arrangement plan may not practice. May a PA practice in a manner inconsistent with an approved practice arrangement plan? No. Whenever a PA practices in a manner inconsistent with the practice arrangement plan approved by the MQAC, the MQAC may take disciplinary action. What is the supervising physician s liability for the acts and omissions of a PA? Both the supervising physician and the PA retain professional and personal responsibility for the acts and omissions of the PA. A supervising physician may be disciplined for aiding and abetting the unlicensed practice of medicine if the PA is permitted to practice medicine beyond the scope of practice approved by the MQAC. May a PA prescribe legend drugs? Yes. A PA may prescribe legend drugs, when approved by the MQAC and assigned by the supervising physician, for a patient who is under the care of the supervising physician. A certified physician assistant may prescribe legend drugs when approved by the MQAC. May a PA prescribe controlled substances? A PA may not prescribe controlled substances unless specifically approved by the MQAC. A certified physician assistant may prescribe controlled substances. Whose DEA number must a PA use if approved by the MQAC to prescribe controlled substances? On written prescriptions for Schedule II through V controlled substances, a PA who is approved by the MQAC to prescribe controlled substances must include the PA s DEA registration number or, if none, the sponsoring physician s DEA registration number, followed by the letters P.A. (or if the PA is a certified PA, the letters P.A.-C ), and the PA s license number. May a PA practice in a remote location other than where the supervising physician is located? Yes, but only under limited circumstances and with MQAC approval. A physician assistant who holds an interim permit may not practice in a remote location. The MQAC may approve a PA s practice in a remote site if: There is a demonstrated need for such utilization. Adequate provision exists for immediate communication between the supervising physician and the PA. The responsible sponsoring or supervising physician spends 10% of the PA s practice time in the remote site, or in the case of part-time or unique practice settings, demonstrates that adequate supervision is being maintained by an alternate method. The names of the sponsoring or supervising physician and the PA are prominently displayed at the entrance to the clinic or in the reception area. Must a physician review and countersign chart entries made by a PA? Chart entries made by a physician assistant must be reviewed and countersigned within two working days, unless another time period is permitted by the MQAC. Countersignature of chart entries made by a certified physician assistant is not required. Physician Assistants in Washington State Page 18

19 What should a supervising physician do when unable to supervise due to a temporary absence? The supervising physician must identify a designated alternate supervisor who will take over supervisory and review responsibilities in the supervising physician s absence. What are the responsibilities of a nonsupervising physician who utilizes or advises a PA? A nonsponsoring physician who knowingly requests a PA to render care to a patient or knowingly consults with a PA is responsible for the care provided by the PA. What happens if the sponsoring or supervising physician s practice is limited by disciplinary action? To the extent the sponsoring or supervising physician s practice has been limited by disciplinary action, the PA s practice is similarly limited while working under that physician s sponsorship or supervision. Are there requirements for continuing medical education for PAs? Yes. Physician assistants must complete one hundred (100) hours of continuing medical education every two (2) years. Physician Assistants in Washington State Page 19

20 Appendix E Osteopathic Physician Assistants WSMA: Washington Physicians Guide to Health Law What is an osteopathic physician assistant? An osteopathic PA is a health care provider who is licensed by the Board of Osteopathic Medicine and Surgery (Board) to practice osteopathic medicine to a limited extent only under the supervision and control of an osteopathic physician. The osteopathic PA must be physically and mentally capable of practicing osteopathic medicine with reasonable skill and safety. All osteopathic PAs must wear identification or a badge identifying him or herself as an osteopathic PA at all times when meeting or treating patients. What is the difference between an osteopathic physician assistant (PA) and a certified osteopathic physician assistant (PA-C)? A certified osteopathic physician assistant (PA-C) is an individual who has successfully completed an accredited and approved physician assistant program and has passed the National Commission on Certification of Physician Assistants examination. Effective July 1, 1999, an individual applying for a license as a physician assistant must have graduated from an accredited and approved physician assistant program and must be certified by successful completion of the national board examinations. Applicants for an interim permit will have one year from issuance of the interim permit to successfully complete the examination. An osteopathic physician assistant (PA) is an individual who successfully completed an accredited and approved osteopathic physician assistant program and was licensed in Washington State prior to July 1, 1999: An osteopathic PA may also be an individual who holds an interim permit prior to passing the certification. What must an osteopathic physician do to utilize a PA in the osteopathic physician s practice? An osteopathic physician who wishes to use a licensed osteopathic PA must obtain approval from the Board. Before commencing practice, a licensed osteopathic PA must apply to the Board for permission to be employed or supervised by an osteopathic physician or physician group. The osteopathic physician or physician group and the licensed PA must jointly submit to the Board a practice arrangement plan which delineates the manner and extent to which the osteopathic PA will practice and be supervised. A licensed osteopathic PA may practice osteopathic medicine only with the Board s approval of the practice arrangement plan and only to the extent permitted by the Board. A licensed osteopathic PA who has not received approval of the practice arrangement plan may not practice. May an osteopathic PA practice in a manner inconsistent with an approved practice arrangement plan? No. The Board may take disciplinary action against an osteopathic PA who practices outside the approved practice arrangement plan. Physician Assistants in Washington State Page 20