Trying to Cover Overhead? Top 5 Reimbursement Threats for Mid-level Services

April 21st, 2011 2 Min read Trying to Cover Overhead? Top 5 Reimbursement Threats for Mid-level Services Blog
Running a medical practice may feel like that new Nissan commercial where the woman is carrying a stack of items taller than her car and her precariously balanced pile contains everything from fresh flowers to her 5-year-old daughter dressed for karate class. She manages to get it all together very neatly, and you can do the same by ensuring that your mid-level providers are reimbursed properly. In our current healthcare climate, there are several reimbursement threats that will dissolve your bottom line without careful attention:
  1. Medicare Does your practice REALLY understand "incident-to" services? Do you know all the rules, i.e. when the doctor has to see the patient, when a problem is new or established? Is the documentation and coding sufficient? Are you capturing all of the pertinent information in the record, or are you leaving money on the table?
  2. Medicaid State budgets are tapped. Some states want to limit reimbursement even in federally qualified health centers. In an attempt to balance budgets, Medicaid rates are under constant scrutiny, and physician groups are lobbying to minimize this every year. What is your payor mix, and does it need to be adjusted?
  3. Third-party payor changes New BCBS and Aetna policies are limiting (mirroring) Medicare incident-to rules with no provision for incident-to "capture" of funds. What are the newest changes in your state? If a majority of your claims are from third-party payors, your cash flow may be significantly affected.
  4. Uninsured/Underinsured Clinics and hospitals are going to have to consider alternate payment models for cash-paying patients. With health reform changes looming, these uninsured patient numbers may decrease; however, there are a number of people who may be moving to healthcare savings plans, and consumer demand will push for greater transparency in fee schedules. Do you have a cash-paying patient policy?
  5. Perpetuation of myths and bad information Practice managers, consultants and office administrators may have little to no understanding of the supervision requirements or the clinical capabilities (and therefore "bill-ability") of PAs and NPs. Don't settle for being told "PAs or NPs cannot do that." Check with the national professional associations or state academy leaders for accurate information.
Are your supervision and documentation requirements being met? Medical billing and reimbursement are the core foundation of every practice and health system. Examination of each of these principles and addressing the above questions for your medical practice will ensure your success in improving overall reimbursement and cash flow.


Lisa Shock

Lisa Shock

Lisa P. Shock, MHS, PA-C, is a seasoned PA who is the President and CEO of Utilization Solutions in Healthcare – a specialty consultant company for physician practices and hospitals, offering a wide range of services to help implement and improve upon the utilization of PAs and NPs in the health care system. Contact her at

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