Reimbursement

PA services are reimbursable at a percentage of the physician rate by most major federal programs, insurance companies and workers' compensation programs.

Reimbursement at a Glance

PAs are reimbursable under Federal Health Laws that regulate Medicare. Most insurance companies also cover services performed by the physician/PA team. The Medical Group Management Association 2001 Physician Compensation survey found that the average total charges for a surgical PA in that year was $321,225.

 

Medical Reimbursement

Care Setting

Reimbursement Rate

Office/Clinic when physician is not on site Home visit/House Call
Skilled Nursing Facility & Nursing Facility
Hospital; non-shared visit service

85% of physician fee

First assisting at surgery in all settings

85% of physician first assist fee schedule

Office/Clinic when physician is on site
Hospital; shared visit service

100% of physician fee

Federally Certified Rural Health Clinics

Cost-based

HMO

On capitation basis

 

Other Reimbursement

Reimbursing Program/Entity

Reimbursement Rate

Medicaid fee-for-service or managed care programs

Varies by State
from 68%-100% of physician fee

Private insurance programs (fee-for-service, HMOs, PPOs, etc.)

Varies by Program
most provide at least partial reimbursement

Workers’ Compensation

Varies by State
from 53% to 100% of physician fee,
some depend on insurance policy

TRICARE (formerly CHAMPUS) covers all medically necessary services

Varies by Program
TRICARE Standard: 65% for first assisting,
85% for comparable services

 

For more information on PA reimbursement, visit AAPA.org.

More Information

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