The
Massachusetts Medical Society appreciates the opportunity to provide comment
regarding the proposed changes to the MassHealth Provider Manual Series (130
CMR 433.000). Specifically, the Medical Society wishes to share concern with
the proposed changes to the Certified Nurse Practitioner Services and the
Physician Assistant billing regulations, each contained in Section 433.433.
The
Medical Society has long supported team-based care that utilizes many allied
health professionals, including certified nurse practitioners (CNPs) and
physician assistants (PAs). The Medical Society supports the intent of these
regulations as they relate to nurse practitioners, which require compliance
with all existing scope of practice laws and regulations, but which allow the CNP
to choose to bill MassHealth via the “independent provider” route, as outlined
in 433.433(C), or via the “nonidependent certified nurse practitioner” route,
as outlined in Section 433.433(E). However, the Medical Society has concern
about some of the details of these regulations, as proposed.
First,
there appears to be an inconsistency between 433.433(C) and 433.433(E). In
433.433(C), the regulations indicate that certified nurse practitioners may
choose to enroll as an independent certified nurse practitioner, if
they meet the requirements as laid out in the subsections 1 and 2 of the
section. Section (E) of 433.433 then indicates, however, that nonindependent
certified nurse practitioners are those who do not meet the requirements of
433.433(C), which does not acknowledge CNPs who meet the requirements of
Section (C) but choose not to enroll as independent nurse practitioner, as is
their right per the language of Section (C). The Medical Society thus urges the
striking of the language “who does not meet the requirements of 130 CMR
433.433(C)” to clarify that all qualified CNPs have the choice to bill as
independent or nonindependent CNPs. The Medical Society is unclear about the final
sentence of Section (E) which references the application of this paragraph to
physicians who are not practicing as professional corporation or not as a
member of a group practice. The Medical Society does not understand the
relevance of each of these factors to the billing policy and regulation.
In sum,
the Medical Society urges flexibility on the part of the care team to determine
if it is in their best interest to have certified nurse practitioners bill
independently or through the physician, so that they can then use the various
billing options, including incident-to billing using the SA modifier.
Lastly,
while updating the regulations to no longer reference outdated collaboration
agreements makes sense, the Medical Society wishes to remind the agency that
CNPs are still required to have prescribing guidelines mutually developed with
a physician. These guideline requirements should be referenced in these
regulations.
The
Medical Society also wishes to comment on the reimbursement of physician assistant
services. While we do not have issue with the changes proposed in these
regulations, we do have concern about these regulations as they relate to the
proposed changes to EOHHS regulations, 101 CMR 317.00. The EOHHS regulations
(101 CMR 317.04(3)) eliminate the “HN Modifier” used for service codes billed by a physician which were performed by
a physician assistant employed by the physician or group practice.
Incident-to
billing, that is, the practice of billing select services by health care teams
members such as physician assistants under the physicians NPI, 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 physician assistants 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, 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 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 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.
