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