Drs vs PA - their rates and insurance payments

[whoisjohngalt]

I recently went to a specialist, a surgeon.  Well, not exactly.  I only saw his PA.  When I looked at the billing details on my insurance website, it shows that insurance was charged as I went to see him.  So, it was a $400 visit to see a PA for about 10 min.

A few years ago my husband was seeing a specialist too.  He was suppose to be one of the "best".  He spent may be 3-4 min with my husband, the rest of the time was spent with his assistants.  Again, the same thing.  The insurance was charged the rate that is charged by surgeons. 

I have other examples where my insurance was charged in a way, that I thought was unfair or just plain wrong.

So, to those who say that health care costs so much bc doctors paid so much for their education - I think you are wrong.  I think one of the reasons the costs are so high is bc it's just plain over inflated.

[Deleted]

I don't know about your insurance, Lena, but mine only pays a "negotiated" rate. The specialist may charge $400 for the visit, but the insurance company is only going to pay $200.   

I can see in that scenario why the physician is using the PA wherever possible. They aren't getting paid their going rate.

I will say that the PA model hasn't caught on or something in Alabama because DH sees LOTS of specialists, particularly cardiac specialists, in a system that is part of a major medical university.  The specialist does the actual diagnosis, treatment plan, etc. It is true that some sort of assistant (nurse practitioner, I think) often sees him first and interviews him.  But then the specialist comes, and the assistant fills the doctor in on the history, symptoms, etc. 

It is probably a very efficient model for what is probably an extremely expensive specialist.  One thing I loved about this guy is that he took his time, which was likely possible because he didn't have to interview DH.  He knew what DH's primary concerns and questions were immediately.  Yet the guy still took time at the end to answer additional questions.

[Sharon]

I am guessing that the insurance website shows the specialist because he owns the practice so he what they call the billing doctor.  They are billing under his tax id.  The insurance payments go to him and then he pays the PA.  At the end of the year the 1099 from the insurance company also goes to him.  The PA was probably billed under what they call the rendering provider, if he has a NPI (National Provider ID).  Based on the EOB's that I see they usually list the billing provider because that is who is receiving the check.

[milee]

Here's what we've experienced with physician extenders over the last year or two:

Pediatrician - the office has both regular MD and also a PA and a Nurse Practitioner (NP).  For regular office visits, the negotiated rates vary hugely. MD is around $40-$50, NP is $17 and PA is somewhere in between (I think in the upper $20s or low $30.)  We like all three of them and when I get a choice, I have the kids see the NP or PA, especially for routine stuff and even DX minor ailments.  IMHO the pricing for all three is extremely reasonable.

Pediatric spinal surgeon specialist - works a little like you describe.  We're there for about 45 minutes.  First 15-20 are spent getting special x-rays.  Next 15-20 are spent with the doc's PA.  Then the results of those two are studied by the surgeon, who then comes into the room and spends about 3-4 minutes examining DS and talking to us.  For that entire thing, we get one bill with one line item that looks like we just saw the surgeon.  The negotiated rate for that is around $200.  I think that's a very reasonable deal given the x-rays and total time spent with the team.

My dermatologist has an excellent PA.  Unless there's something really unusual going on, I ask to see the PA.  The dermatologist's pricing is around twice that of the PA.  I think it's something like $60 for the dermatologist and $35 for the PA.  For the types of things I have done (mostly skin cancer checks, biopsy suspicious areas, freezing suspicious areas, other general skin concerns) the dermatologist's prices seem a little high and the PA's seem a little low, so I guess it all evens out.

[whoisjohngalt]

Just for the record, I didn't have a problem seeing PA.  However, I am getting a second opinion at the end of the month, another surgeon, same specialty and this time I am actually seeing the surgeon so it will be interesting to see if the rate is similar or much higher.

Yes, Sharon you might be right as to why insurance site shows his name and not PA's.

I'll admit, I am very jaded about how dr offices charge insurance companies.

I understand all about pre-negotiated rates so it's not about that, but about how services are billed. 

may be I am too cynical, but I think there is a lot/some over billing going on.

[sapphire12]

My orthopedic surgeon is overbooked and it can often take 3 weeks to get in to see him. When I tore my rotator cuff, I didn't know it was torn at that point, but I made the initial appointment with the PA. She sent me for X-rays and a MRI. She also administered the cortisone shot. Whether I saw the surgeon or PA, neither could definitely say I had a torn rotator cuff until the MRI results came back. The physician read the images. My follow up appointment I saw the surgeon.

Since I am not new to this practice, I willingly made the decision to see the PA initially. It started the ball rolling.

During his surgeries on Tuesday, the PA is also in surgery for OJT. The PA doesn't do any surgery, but does see what takes place during surgery.

Where I go, the patient knows if he/she will see the PA or the surgeon before each visit. At some visits you see both.

Insurance is billed under his name as he is the physician in network. To me it is a cost of doing business, the surgeon chose to hire a PA.

The payment is negotiated by insurance based on services rendered.

An injection is an injection; doesn't really matter who did the procedure. I'm paying for the medicine.

[zibazinski]

We get charged the same whether we see the nurse, nurse practitioner, PA, or doctor.

[whoisjohngalt]

Dec 8, 2014 15:21:33 GMT -5 zibazinski said:

We get charged the same whether we see the nurse, nurse practitioner, PA, or doctor.

See, to me, it doesn't make sense.  What am I missing here?

[zibazinski]

Fortunately everyone we see is good at what they do. But there's no deal for seeing anyone less qualified than the doctor.

[wvugurl26]

When I landed in the ER after my car accident I was seen by a PA. I didn't have a choice. The part that annoyed me was the PA was a contracted employee of the ER so I paid a $100 copay to the ER and a specialist copay to the contract company that employs the PA. Now that pissed me off.

The only one who had a setup like you described was the pain specialist. I was slightly annoyed for those appointments where I went in and only saw the PAs. And they had a medical assistant who did history and blood pressure and all that stuff first. I was referred to the pain specialists for cervical injections which the PA can't do. So for those visits where he wasn't anywhere to be found I wasn't getting what I was sent for.

[zibazinski]

   That is not how it's supposed to happen.

[justme]

I pay the same for either and after having been burned by PAs not being able to solve what I went for or explain things well I now only see them for sick visits when I can't see a Dr but need to see someone.

[zibazinski]

I prefer the NP's over the PA's    

[busymom]

I got burned by a NP years ago.  My doctor was overbooked for my yearly exam, I wasn't told until I walked in for my appointment, so would I mind seeing the NP instead?  Well, I was already there, so I agreed to see the NP.  It turns out one of my ovaries had gotten HUGE, & although I remember her pressing over that side of my stomach some extra times, & she made a face, she decided it was nothing & sent me on my way.  (This was in the Spring.)  That Summer I was in the ER in extreme pain, & the surgeon was FURIOUS, because I hadn't skipped my yearly appointment, & that ovary would've killed me in another couple of days.  (I was bleeding internally.)  So, the surgeon removed that ovary, & I've been his patient ever since...

I don't like the idea that my insurance could be billed at the same rate seeing an assistant over a doctor. 

[zibazinski]

I don't like it, either, but it is what it is.

[The Walk of the Penguin Mich]

My orthopedic surgeon has 3 fantastic PAs.  I have absolutely no problem seeing any of them for my follow ups.  In fact, whomever was on call was responsible for my care while I was in the hospital and I got more time with them than I did if the surgeon stopped by.  They were willing to take the time to speak to me and answer any and all questions.  Not only that, when I called the surgeon when I thought my second hip was infected, I got incredible results from the PAs - my surgeon was out of town at a conference, and when it turned out that I was infected, he cut short his conference to come back and take it out (and missed out on a day of skiing).  He has a tremendous amount of trust in the 3 PAs he hired, but when they say he needs to be home, he comes running.

I figure it this way.....they are the eyes and the ears of my surgeon and they know what to look for.

I also consider that if they are taking some of the 'scut' work away from my surgeon, it means that he becomes more available to me (and others) if I need surgery.  I don't need to see my surgeon to get my staples removed, but I DO need the surgeon to cut on me.  There is already a 3-4 month wait for surgery, if the surgeon had to cover more of the staple removal stuff, it's likely his wait would be 3x as long.