Medicaid - Medicaid is a program whereby federal and state governments share the cost of providing approximately 58 million needy Americans with health care coverage. To qualify for the program, states must include hospital services, prevention services, skilled nursing and home health care coverage for adults, and prevention and treatment services for children.
Unlike Medicare, Medicaid has a state funding component, and allows each state to write its own rules for medical coverage. Therefore, every state may define PA scope of practice and reimbursement rules.
Private Payer - Nearly all private payers reimburse for services provided by PAs; however, insurers may have different policies regarding how PAs are credentialed, what services PAs may provide, and how services provided by PAs should be billed. In general, when state laws are followed, insurance plans cover PAs providing medically necessary services that are within the scope of PA practice.
Many payers request that PAs submit claims for medical services under the physician’s name and provider number and reimburse for the PA’s services at the same rate a physician would receive. Some payers, however, individually credential PAs and ask that claims be submitted with the PA’s name and number.
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 specific billing exceptions discussed below ("incident to" and "shared visits billing") apply. To receive reimbursement, PAs must bill Medicare at the full physician rate. 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. It is also required for Medicare providers to enroll via the PECOS system.
Workers' Comp - Workers’ Compensation provides insurance to employers to provide benefits and care to employees injured on the job and benefits to families of those killed on the job. Like Medicaid, Workers’ Compensation, also known as industrial insurance, is administered by each state and, likewise, each state determines its own rules regarding PA reimbursement and scope of practice.