PA owned practices?

[ssamalin]

I'm a CA PA thinking of independent contracting. Anyone interested in hooking up with other PAs in some sort of group owned practice?

[Guest wannabepa132]

I started out trying to create a PA-owned urgent care clinic, but (as you know) before I could secure a SP, an NP (who didn’t not need a relationship with an MD) took the same office space and opened one. She has asked me to be her partner, but the expense of an SP (for me only) would be make that impossible, so she is looking for another independent NP.

 

 

Why is it that an NP does not need an SP and a PA does?? That seems really odd?

[Guest docmartin]

Why is it that an NP does not need an SP and a PA does?? That seems really odd?

 

Because PAs are controlled by state medical boards but NPs are not.

 

NPs can do anything they want. They could write new regs giving them the ability to do brain surgery if they wanted, and doctors couldnt do a damn thing about it.

[Guest wannabepa132]

thats messed up! and it sucks! An NP can diagnose, write scripts etc etc same as an PA...they too should be controlled by a state board!

 

 

Because PAs are controlled by state medical boards but NPs are not.

 

NPs can do anything they want. They could write new regs giving them the ability to do brain surgery if they wanted, and doctors couldnt do a damn thing about it.

[themadmedic]

It isn't that simple...and most NPs need more supervision to do what they are doing than what they would like for folks to believe...there's always fine print and more to the story than what is evident at a glance...

[caldje]

It isn't that simple...and most NPs need more supervision to do what they are doing than what they would like for folks to believe...there's always fine print and more to the story than what is evident at a glance...

 

right.. and this stuff about the nursing board can write whatever they want isnt exactly true either. Laws are made by congress and boards of whatever cannot surpase the limits put on them by the state legislative bodies. Not only that, but the board of nursing could write a scope like, "NPs can do whatever they want." one sentece.. the whole PAN practice act and in the end the APNs would still have to answer to patients, malpractice lawyers, etc. It just isnt as simple as anyone, especially NPs, make it out to be.

 

chris

[themadmedic]

right.. and this stuff about the nursing board can write whatever they want isnt exactly true either. Laws are made by congress and boards of whatever cannot surpase the limits put on them by the state legislative bodies. Not only that, but the board of nursing could write a scope like, "NPs can do whatever they want." one sentece.. the whole PAN practice act and in the end the APNs would still have to answer to patients, malpractice lawyers, etc. It just isnt as simple as anyone, especially NPs, make it out to be.

 

chris

 

It is even bigger than that...

 

Like sure, a NP can practice completely independantly...unless s/he wants to Rx then has to have a collabarative agreement with a physician-which looks the same as many of our arrangements with our SP's...

[jmj11]

I just received this response from an insurance company to an inquiry that I made about a PA-owned clinic. Can any one explain why an insurance company would turn down better care, for lower cost (to them) unless it were:

1) insecurity of the MDs involved, or

2) mis-information or sterotyped misconception about the knowledge and skills of a PA?

 

Dear Mr. Jones:

Your email inquiry of January 9th reached my desk last week, and I took the opportunity to discuss with our NW District Medical Director, Dr. Donald Rappe.

While you are always welcome to apply formally via our Interested Provider Process, both Dr. Rappe and I felt it would be more expedient to answer your email without a formal application. In the event you should desire to apply formally, I have attached the procedure for doing so to this message.

As to your question to Group Health's policy on contracting with private practice Physician Assistants, and PA-owned clinics: Group Health's delivery system is based on personal care physicians offering the full scope of care, which in most cases would include primary management of headaches. In cases where specialty care is needed, referral to an appropriate physician consultant is facilitated by the personal care physician. We encourage and respect the use of Physician Assistants, but as members of a physician-led team practicing in a medical home in the case of primary care and as member of the team in a consultant practice.

Based upon our delivery system design and philosophy of care, we would likely not offer an individual contract to a Physician Assistant operating his/her own clinic.

I hope this provides the information you are seeking, and I apologize for the delay in response.

Thank you very much,

Brian Burch

NW District Provider Services Manager

Group Health Cooperative

Bellingham Administrative Office

2211 Rimland Dr., Suite 124

Bellingham, WA 98226

(360) 714-4266

CDS: 8-520-4266

Mailstop: BEL

[BlocDoc]

I just received this response from an insurance company to an inquiry that I made about a PA-owned clinic. Can any one explain why an insurance company would turn down better care, for lower cost (to them) unless it were:

1) insecurity of the MDs involved, or

2) mis-information or sterotyped misconception about the knowledge and skills of a PA?

 

Because the health care system is still Physician driven and because we are "Physician---Assistants"- PA ownership speaks to a business relationship- You could likely own it as a private individual but yet TIED to a physician principle-

I have gone over the scenario with labor lawyers in the past- The perception is that we are looking to expand beyond the original intention of a non-physician provider- Consider the means by which PA's originated (the original construct) and then re-read the letter.

 

I would be interested in Mr. Bob's opinion on this...

[andersenpa]

In cases where specialty care is needed, referral to an appropriate physician consultant is facilitated by the personal care physician. We encourage and respect the use of Physician Assistants, but as members of a physician-led team practicing in a medical home in the case of primary care and as member of the team in a consultant practice.

 

Read: know your place, boy......

 

Totally disheartening. Group health is known for this BS....

[Guest PA4me]

This is ludacris!! How so I start a thread!!?

[andersenpa]

This is ludacris!! How so I start a thread!!?

 

FYI:

Ludacris is a rapper.

Ludicrous is a word.....

[EMEDPA]

This is ludacris!! How so I start a thread!!?

go to the forum you are interested in. hit the button in the upper right that saws "new thread". type away

[bsady]

Easy to get around this. First off, never tell an insurance company who owns the office. A "corporation" should own the office. If they want to investigate who owns the corp, they can do the research of the public records and find out. Otherwise you are not obligated to tell them. Second, you have to have a supervising doc contracted with your fascility. You apply through the formal process with The supervising doc and your name at the same time for your fascility. Usually they will agree to this as long as that md is associated with your fascility. This gets you in the door. Later you can add other providers...MDs, DOs, PAs. If one doc in the future pulls out, you'll have a second doc to take over the contract. You would just have to inform the ins co. that the other doc is no longer associated with your office. Even better...usually after a certain amount of time...they will associate the contract with the fascility name, and when they re-up the contract..if your in good standings...they'll just put the fascility name on the contract. Happens all the time.

[jmj11]

Easy to get around this. First off, never tell an insurance company who owns the office. A "corporation" should own the office. If they want to investigate who owns the corp, they can do the research of the public records and find out. Otherwise you are not obligated to tell them. Second, you have to have a supervising doc contracted with your fascility. You apply through the formal process with The supervising doc and your name at the same time for your fascility. Usually they will agree to this as long as that md is associated with your fascility. This gets you in the door. Later you can add other providers...MDs, DOs, PAs. If one doc in the future pulls out, you'll have a second doc to take over the contract. You would just have to inform the ins co. that the other doc is no longer associated with your office. Even better...usually after a certain amount of time...they will associate the contract with the fascility name, and when they re-up the contract..if your in good standings...they'll just put the fascility name on the contract. Happens all the time.

 

bsady,

 

I'm sure you are right and others (in business) have said the said the same. I think when the time comes that I try to contract; I will follow your advice.

 

At the same time, there is a principle here and it is part of the reason I wanted to start this dialog with Group Health. There needs to come a time when we can boldly announce to everyone that we are PAs and be damn proud of it. We have nothing to be ashamed about because we deliver good care at a good price.

 

I see parallels with the women’s moment in the past 50 years. Say a woman wanted to start a business in the 50s and the banks say no (because she is a woman) and the other businesses in town (all owned by men) say no and threaten to boycott her business, and the insurance company says no because “women make good secretaries but not good business owners.”

 

That woman has two choices. Put the business in her husband’s name and succeed (later letting people realize that it was woman who did it) or to put on her heels, let her hair out and go to each town chauvinists and confront them face to face. There’s a place for both. Maybe at this point in the PA history we have to follow the first approach, but it really rubs me the wrong way. We have nothing to be ashamed about and the system must get out of their Dark Ages of medicine.

 

But, I will probably have to follow you advice to get things off the ground.

 

I wonder what others think.

 

Mike

[andersenpa]

Mike, you're in the unfortunate position of being on the front end of a movement (no sarcasm).....

 

I agree with your principle 100%.

[jonasons]

Mike,

One tact may be to take the threat of "restraint of trade" route.

If an insurer will pay for a specialty referral, then it should not matter who owns the practice.

For instance, what is different now of an MD sends somebody to your neurology practice for chronic HA. Your front desk knows that this is your specialty so they make the initial appt with you. None of your SPs every see the patient and the insurer still pays the bill. You have the specialty training and experience that would qualify you to work as the consult (you have been paid in the past for this right?).

So, provided you meet the state practice guidelines, I would think that an insurer that declines to contract with you soley because you are a PA, when they have paid for your services under the employ of an SP, would be guilty of restraint of trade.

Not a lawyer here, but may be worth the legal council to see if that would give you a leg to stand on.

May even be some help from WAPA.

 

Just my thoughts.

 

Scott

[jmj11]

Mike,

One tact may be to take the threat of "restraint of trade" route.

If an insurer will pay for a specialty referral, then it should not matter who owns the practice.

For instance, what is different now of an MD sends somebody to your neurology practice for chronic HA. Your front desk knows that this is your specialty so they make the initial appt with you. None of your SPs every see the patient and the insurer still pays the bill. You have the specialty training and experience that would qualify you to work as the consult (you have been paid in the past for this right?).

So, provided you meet the state practice guidelines, I would think that an insurer that declines to contract with you soley because you are a PA, when they have paid for your services under the employ of an SP, would be guilty of restraint of trade.

Not a lawyer here, but may be worth the legal council to see if that would give you a leg to stand on.

May even be some help from WAPA.

 

Just my thoughts.

 

Scott

 

I've had those very same thoughts and want to do more reading before I meet face to face with Group Health. I've brought this up with them in a subsequent e-mail. Like you told me in private, don't ask, don't tell is probably the best way to actually run the business, however, I do want have the chance to make a statment before I take the more clandestine route. Thanks. Your views are always deeply respected.

 

I went through a law suit once before over PA rights and won so I feel a little bit more confident about this than I use to.

Mike

[coloradopa]

Mike,

One tact may be to take the threat of "restraint of trade" route.

If an insurer will pay for a specialty referral, then it should not matter who owns the practice.

For instance, what is different now of an MD sends somebody to your neurology practice for chronic HA. Your front desk knows that this is your specialty so they make the initial appt with you. None of your SPs every see the patient and the insurer still pays the bill. You have the specialty training and experience that would qualify you to work as the consult (you have been paid in the past for this right?).

So, provided you meet the state practice guidelines, I would think that an insurer that declines to contract with you soley because you are a PA, when they have paid for your services under the employ of an SP, would be guilty of restraint of trade.

Not a lawyer here, but may be worth the legal council to see if that would give you a leg to stand on.

May even be some help from WAPA.

 

Just my thoughts.

 

Scott

 

 

You really can't use this route in specialty practice. In our area the insurance companies credential the MD's. So to get the insurance to pay for a specialty referral you need a board certification. We had one "old time" GI that was dropped last year because he had never board certified. They are becoming increasingly strict on this. Now if you live in a shortage area, then you may be able to work around this. There are a lot of Doc's in the hinterland practicing specialty medicine without specialty traininig much less certification.

 

David Carpenter, PA-C

[IDFTIGER]

Any info on PA-owned practices in NY?

[bsady]

bsady,

 

I'm sure you are right and others (in business) have said the said the same. I think when the time comes that I try to contract; I will follow your advice.

 

At the same time, there is a principle here and it is part of the reason I wanted to start this dialog with Group Health. There needs to come a time when we can boldly announce to everyone that we are PAs and be damn proud of it. We have nothing to be ashamed about because we deliver good care at a good price.

 

I see parallels with the women’s moment in the past 50 years. Say a woman wanted to start a business in the 50s and the banks say no (because she is a woman) and the other businesses in town (all owned by men) say no and threaten to boycott her business, and the insurance company says no because “women make good secretaries but not good business owners.”

 

That woman has two choices. Put the business in her husband’s name and succeed (later letting people realize that it was woman who did it) or to put on her heels, let her hair out and go to each town chauvinists and confront them face to face. There’s a place for both. Maybe at this point in the PA history we have to follow the first approach, but it really rubs me the wrong way. We have nothing to be ashamed about and the system must get out of their Dark Ages of medicine.

 

But, I will probably have to follow you advice to get things off the ground.

 

I wonder what others think.

 

Mike

You'll have no choice in the matter. Cash clinics...good luck..may pay the rent but no salary for you. I have a lot of experience with owning an office. There isn't one hurdle I haven't had to jump through. I even had to ask a favor of a local CEO of one of the hospitals to make a call to one of the big insurance companies. The ins co front desk person outright rejected my application without ever inspecting my office, or putting my application in front of their board. I'm happy to say that I orchestrated a meeting with my super DO, the CEO, my billing company, and three board members of the insurance co. After the meeting they gave me a 5yr renewable contract in the name of my medical center. Also..that front desk person...she got soooooo fired when the board found out that the application never got in front of their eyes. Its the squeaky wheel that gets the oil folks!

[jmj11]

In our discussions with Group Health, about PA-owned practices, I considred the Group Health response as somewhat postive:

 

My initial email to you was simply intended to generally acquaint you with Group Health's philosophy of care. Group Health does not have a predetermined bias against PA's owning their own clinics, provided these meet all regulatory requirements and would fill a need in our delivery system. That information is thoroughly considered in our formal Interested Provider process. At this point I believe both your interests and those of Group Health would be best served by requesting more information from you via this usual Interested Provider process. That would inform us more thoroughly and allow us to give you an official response, rather than to discuss this informally via email.

Per the information I sent you previously (Interested Provider letter & Q&A), we would need a letter from you detailing your scope of practice, physician supervision arrangements, and personal background information. I have attached a "Request for Information" form that is extremely helpful to us in obtaining an overview of your current or planned practice.

We will look forward to hearing from you.

Brian Burch

NW District

[jonasons]

Wow, that was a quick turn around. What did you say to get them to back track?

[jonasons]

You really can't use this route in specialty practice. In our area the insurance companies credential the MD's. So to get the insurance to pay for a specialty referral you need a board certification. We had one "old time" GI that was dropped last year because he had never board certified. They are becoming increasingly strict on this. Now if you live in a shortage area, then you may be able to work around this. There are a lot of Doc's in the hinterland practicing specialty medicine without specialty training much less certification.

 

David Carpenter, PA-C

 

David, I see your point, but I would still disagree. PAs are also credentialed providers in specialty offices. If I understand the insurers on this, they first follow the guidelines by Medicare on referrals that the specialist must have specific training AND/OR experience (over and above the referring provider) in a given specialty to qualify for a consult code. Once the initial consult is done, then the office visits revert to the traditional 99213-5 codes.

 

If an insurer back tracks on a PA because he is not board certified in a specialty, then wouldn't that open the door to Pandora for all specialty PA's? I don't think the Doc specialty associations would allow any back tracking from the insurers on how they pay for PA consults, so I don't see that happening. Rather, I see insurers being more willing to bill for PA services directly as the way the pendulum is currently swinging.

 

I think they have already set the precedent by recognizing PAs in specialties by allowing them to bill as consults. By refusing to contract with a PA owned practice would, IMHO, still be a restraint of trade issue.

[coloradopa]

David, I see your point, but I would still disagree. PAs are also credentialed providers in specialty offices. If I understand the insurers on this, they first follow the guidelines by Medicare on referrals that the specialist must have specific training AND/OR experience (over and above the referring provider) in a given specialty to qualify for a consult code. Once the initial consult is done, then the office visits revert to the traditional 99213-5 codes.

 

If an insurer back tracks on a PA because he is not board certified in a specialty, then wouldn't that open the door to Pandora for all specialty PA's? I don't think the Doc specialty associations would allow any back tracking from the insurers on how they pay for PA consults, so I don't see that happening. Rather, I see insurers being more willing to bill for PA services directly as the way the pendulum is currently swinging.

 

I think they have already set the precedent by recognizing PAs in specialties by allowing them to bill as consults. By refusing to contract with a PA owned practice would, IMHO, still be a restraint of trade issue.

 

 

Actually almost no PA's (or NP's) are credentialled by insurance companies. Of the 20+ insurance companies that we contract with, I am credentialled with two. Those are in delegated specialty for my SP. I agree that I see more willingness to contract with PA's for primary care, but I haven't seen that extended for specialty care. There is a potential liability for the insurance company in credentialling a PA (or MD) for any practice. While our standards show that we can practice primary care with minimal supervision, there are no studies that show we can practice specialty care with minimal supervision. Unlike physicians they have no way of evaluating our training. Our office has discussed this with multiple insurance companies and they prefer not to know how the billing is done. We submit almost all of our billing under our physicians.

 

My impression of the billing situation is that they do not recognize specialty PA's. Instead they recognize specialty physicians and choose not to delve into how they run their office. If those physicians choose to employ PA's to do the consults that is their business. I also think that you misunderstand the way insurance payments and contracts work. There is no "right" to be contracted by an insurance company. In some states there is specific language that PA's must be reimbursed for certain services such as first assist if they reimburse physicians for the same services. There is however no right to get a contract in the first place. Unless you show collusion to deny services they can choose not to contract with you for any or no reason. In addition if they so choose they could send you a contract that says they will reimburse for physician, but not PA services. If you go to the reimbursement seminar at AAPA you will see this scenario covered. We have had this happen twice. Both time the CEO sent the contracts back with that stipulation removed. The payors were given the choice of accepting the contracts as amended or not contracting (its good to be in a shortage specialty).

 

The real question is what will happen when the NPI becomes more active in May. We are submitting under our NPI for medicare/medicaid and still submitting under our physicians NPI with our NPI included for private insurance. Not sure what will happen in May. PA's have gone under the radar for a long time with private insurance.

 

David Carpenter, PA-C