Senate Bill 154 took effect on May 17, 2006. The bill greatly expanded the scope of practice for physician assistants (PAs) in Ohio by, among other things, enabling PAs to see new patients and write prescriptions, subject to certain limitations. Subsequent to the bill’s passage, the State Medical Board issued rules, effective on October 31, 2007, implementing Senate Bill 154. The Ohio Department of Job and Family Services (ODJFS) has now disseminated new Medicaid reimbursement rules regarding PAs, effective on February 16, 2009. The key provisions of these new Medicaid reimbursement rules are included below.

Supervision Definition Standardized

The definition of “supervision” for PAs in the Medicaid reimbursement rules has been changed so that it mirrors the three-part definition of supervision in the Medical Board rules governing PAs. PAs will now be subject to direct, on-site, or off-site supervision, depending on the type of procedure they are conducting, under both the Medical Board rules and the Medicaid reimbursement rules.

This necessary harmonization of the supervision definition eliminates the discrepancy that existed between the Medical Board rules and the previous version of Medicaid reimbursement rules regarding, among other things, how quickly the supervising physician needed to be able to reach the PA during offsite supervision. Sixty-minutes travel time is now the standard under both the Medical Board rules and the reimbursement rules.

Medicaid Coverage of PA Services Increased

The new Medicaid reimbursement rules make a significant change to PA reimbursement by eliminating the prohibition against PAs billing for seeing new patients, seeing existing patients with a new condition, or admitting and discharging patients to a hospital without a physician also seeing the patient. Under the previous reimbursement rules, PAs could not initiate a plan of care on either new patients or existing patients with a new condition until the patient had been seen and personally evaluated by the PA’s employing physician. PAs also could not admit or discharge patients to a hospital without the supervising physician examining the patient. These restrictions are not present under the new reimbursement rules.

Under the new reimbursement rules, PA-provided services and procedures are reimbursable under Medicaid only if the following requirements are met:

  • Services are provided in accordance with the Medical Board rules governing PAs in Chapter 4730-1 of the Ohio Administrative Code;
  • Services are specified in O.R.C. 4730.09 or, if beyond the scope of those services listed in O.R.C. 4730.09, have been approved as special services for that particular PA by the Medical Board;
  • Services are within the scope of practice of the PA’s supervising physician;
  • Services are covered by Medicaid under O.A.C. 5101:3-1-60 and not specifically excluded by the new reimbursement rules (see below);
  • PA is employed by or under contract with a physician, physician group practice, or clinic; and
  • PA provides the services in compliance with all applicable state laws.

The new reimbursement rules also provide that reimbursement may be issued for PA evaluation and management services commensurate with the PA’s training, experience, the scope of practice of the supervising physician, and the physician supervisory plan.

Reimbursement Rate

The new rules have simplified and modified the rate at which various services are reimbursed when performed by a PA. Generally under the new rules, services provided by a PA must be billed using the appropriate five-digit procedure code with the UD modifier. Reimbursement for such services will be at the lesser of the provider’s billed charge or 85 percent of the Medicaid maximum.

Services provided by a PA must be billed using the appropriate five-digit procedure code without the UD modifier when a physician provided distinct and identifiable services in addition to those services provided by the PA during the visit or when the services provided by the PA are services of the type usually provided by medical personnel below the PA or APN level of education, e.g., collection of specimens or immunizations. The reimbursement for these types of services will be the lesser of the provider’s billed charge or 100 percent of the Medicaid maximum.

As was true under the former reimbursement rules, reimbursements for PA services are not payable to the PA directly, but can only be paid to the physician, physician group practice, or clinic employing or contracting with the PA. PA services continue to be subject to the site differential payments in all places of service as specified in O.A.C. 5101:3-4-02.2

Reduction of Services Excluded from PA reimbursement

The new rule excludes the following services from PA reimbursement:

  • Assistant at surgery services;
  • Visits and/or procedures provided on the same date of service by a PA and the PA’s employing physician, physician group, or clinic that are billed as separate services;
  • Consultations and critical/intensive care services (though the rule does recognize that services provided by PAs in such circumstances are highly valuable to the physician and the patient); and
  • Services prohibited by the requirements of the PA supervision rule, O.A.C. 4730-1-03.

Nursing and Intermediate Care Facility Reimbursement

Under the new rules, the employing physician, physician group practice, or clinic may be directly reimbursed for PA services performed in a nursing facility or an intermediate care facility for the mentally retarded.

Reimbursement for Hospital-Employed PAs

The new rules clarify that there is no separate reimbursement for services provided to a hospitalemployed PA. The reimbursement for such services is bundled into the facility payment made to the hospital.