Testimony In Opposition to Proposed Changes to Regulations of the Executive Office of Health and Human Services, 101 CMR 317.00

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.

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