Need help quickly

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Tampa, FL
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How does Medicare pay? Do they pay based off of the referring physician, supervising physician, or rendering?

A PA at one location is listed as rendering. A doctor at another location is listed as supervisor and referring.

I'm brand new to this office and to this side of Medicare.
 

mitchellde

True Blue
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Columbia, MO
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I am not sure I understand your question. Medicare pays based on many factors, can you rephrase the question or put into a billing context?
 
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254
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Tampa, FL
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I am not sure I understand your question. Medicare pays based on many factors, can you rephrase the question or put into a billing context?
I'm not for sure what you mean by put it into a billing context.

Medicare has very specific rules when billing and what payment one will receive when a PA performs the work as opposed to the physician performing the service.

If the physician is listed in referring and supervising...is Medicare paying us based on the physician's rate? Or are they paying us based on the PAs rate (which is lower) if he/she is listed in the rendering?

I hope this makes more sense.
 

mitchellde

True Blue
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If you put the Physicians NPI number in box 24J as the supervising/rendering, then you are billing incident to and the payment will be at the physician rate. If you use the PA NPI number then you are paid at the PA rate. But if you are going to bill incident to them you must meet the incident to definition. Which means the physician must have already examined the patient for the exact same issue and must have a plan of care in the chart which details that the patient will return for an encounter with the PA, and the provider must be within the office suite area while the patient is there. MCM sec 2050
 

CBaer

Networker
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Harrisburg PA
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Medicare and PA reimbursement

When a claim is submitted under a non-physician practitioner or PA NPI, Medicare reibursement will be at 85% of the medicare allowed amount where a physician is reimbursed at 100%. It is the rendering physician listed in block 31 on the claim form

You can find the information you are looking for in CMS Internet Only Manual
http://www.cms.gov/manuals/downloads/clm104c12.pdf

Subchapter 110 - Physician Assistant (PA) Services Payment Methodology
 
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Thank you both. I knew what I was looking for in the system, but not specifically on the claim form. I'm new at this office and it took me ages to even figure out where I could see the claim form!

So, if I need to call the fraud hotline...do I get a lawyer first, or do I just quit my job...basically, just assume there is fraud going on without me going into details. Can someone tell me what my next steps are?
 
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