The Balanced Budget Act of 1997 was unquestionably a frontward step for advanced practice nurses (APNs).  Payment is remarkably allowed for all settings as long as no other provider fee or other facility fee was being paid in relationship to the assistance supplied by the APN.  The various constraints on settings for services provided by the advanced practice nurse were totally removed from the guidelines (Bardach, 2006).

The regulations for reimbursement of APN services typically changes based on the category of setting. Within the office setting, the permissible reimbursement to nurse practitioners is only 85% of that of a physician. This same reimbursement is acceptable only if billed straight under the nurse’s name and provider number (Fishman, 2002).

The decrease in conversion factor for Medicare for reimbursement has affected rural clinics. This paper will discuss some pressing issues regarding reimbursement for nurse practitioners.

I. Crucial Areas for Reimbursement that Nursing Practitioners Should Know

1. An advance practice nurse (APN) should be responsible and aware of the reimbursement process. APN must have read the participation contracts involved. They must determine the following:

Does the plan credentials the APN and assigned a provider number.

What are the claim submission requirements?  It could be direct billing or billing which is conducted by a supervising physician. And what are the time frames for submission.

Can appeal mechanisms for claims denial be conducted?

What are the covered services?

Is it reimbursement methodology capitation or fee for service, etc?

2. An APN must familiarize documentation requirements in order to support the Certified Performance Technologist or CPT. Last 2001, the Office of Inspector General had conducted reviews on nurse practitioner, clinical nurse specialist and assistants of physicians. This is to comply with the Health Care Financing Administration or HCFA rules and regulations. (Cooper, 2000)

II. Understanding the Reimbursement Procedure

In order to better understand the underlying reimbursement issues in nursing practitioner, we must first have a clear grasp on the reimbursement process itself. In 1965, two methods, the Medicare and Medicaid of Social Security Act were amended by the Congress. These two will be discussed thoroughly in the next sections of the paper.

With the first method, Medicaid, 100% of the physician rate is reimbursed. This will only apply if the “incident to” criteria are met. The phrase “incident to” refers to the services provided by nursing practitioners where a physician is actually present, or available for consultation. In order to verify the presence of the attending physician, the patient’s contact, appointment schedule or a documentation of the medical records can be used.

The local Medicare will give the nursing practitioner a unique identification number (UPIN) for his or her bills. For a direct reimbursement, a practitioner must undergo an application process conducted by the payer.

With the second method, Medicare, the nursing practitioner receives 80% of the fee that is set by the practice. Or they also have the chance to receive 85% of the Medicare physician fee schedule. One disadvantage of this method is that it reimburses the lowest charge possible. Citing an example, a practitioner’s bill for his or her services is $120 and Medicare only allows $100, the practitioner will only reimburse $85, which is 85% of the Medicare allowable. (Rapsilver, 2000)

II. General Issues

There are various notable issues connected to the reimbursement for services provided by the APNs. They are expected to take possession and responsibility of the procedure on the reimbursement. The APNs should first begin with comprehending their involvement contracts with health care plans to ascertain the following items (Fishman, 2002):

if the said health care plan will give credit to the nurse practitioner involved and will consequently assign a provider number,

if there are any appeals procedures for denials of claims,

if it is possible to review the comparison of fee for service versus the plan’s reimbursement methodology capitation, etc.,

if claims such as billing under the administering physician’s name or direct billing ask for requirements to be submitted within a specific timeframe; and,

if all specific services are covered

On the secondary topic, nurse practitioners should become familiar with various requirements when it comes to documentation to sustain appropriate CPT coding. APNs should refer themselves to the HCFA rules and the Federal register for guidelines (Bardach, 2006).  The nurse practitioner should actively participate on internal audit of documentation to find out if their documentations support the CPT code billed.

APNs should responsibly scrutinize an illustration of their assortments against their monthly charges. This guarantees that reimbursements are properly made according to contract and that no charges are being denied. (Kansas Nurse, 2008).

III. Medicaid Reimbursement Process Issue

The lack of consistent progress in the Medicaid hospital reimbursement processes has left the nurse practitioners confused and disappointed over the past few years. Progress towards simplifying the Medicaid reimbursement process has been slowed by the absence of relevant policies in hospital reimbursement, memberships, and the level of access for the members (Fishman, 2002).

The lack of priority and actions from the leaders of healthcare to implement the policies for the Medicaid hospital reimbursement processes resulted to the decline in the productivity of the program and posed major setbacks for nurses. With the necessary improvements not being achieved, the government is left with nothing to use in integrating the needed reforms in the Medicaid hospital reimbursement processes.

Suspended reforms for Medicaid hospital reimbursement processes reveal incoordination among various health departments which significantly affected Medicaid members. The adverse effects of the current economic crisis put local governments in a state of uncertainty whether to pursue plans of implementing the new Medicaid hospital reimbursement processes to handle the health needs of their residents (Farley, 2000). Over the past few years, the local governments have been limited with their actions to completely adopt the new Medicaid hospital reimbursement processes.

In New York alone, residents that are not yet affiliated with Medicaid have reached a number of almost 4 million. New York, however, is still way ahead in terms of progress as compared to other states in America. Still, according to Bardach (2006), the majority of New York residents are completely dependent to the Medicaid program because: (1) Medicaid assists them in the access of health benefits; (2) Medicaid assists them by means of health insurance. Yet these Medicaid policies also led to New York’s health issues due to the lack of coordination by the leaders.

IV. Medicare Reimbursement Process Issue

Many advanced practice nurses inaccurately presuppose that receiving an APN license eliminates all obstructions to getting reimbursements for all their services by the insurance companies.  The primary goal obviously is to achieve “direct reimbursement”, which basically means being able to bill in the APN’s exact name and not that of the or under the physician.  This is because being billed under a doctor’s name austerely propagates the invisibility of the nurse practitioners (Fishman, 2002).

To accomplish this goal of straightforward reimbursement, advanced practice nurses have to be “empanelled” by a reimburse-er or have to get a “provider status.”  The methodology for Medicare had primarily implicated achieving a PIN or a Provider Identification Number, which has now transformed into the new NPI or the National Provider Identifier (NPI).

In reality, as an example, Medicare already was issuing PINs to advanced practice nurses in Illinois two years before the APN regulations for practice were written.  Comparatively, Medicaid in Illinois was also agreeable to directly reimburse advanced practice nurses even before Medicare (Bardach, 2006).

The frequent misconception of many advanced practice nurses about Medicare is that if a contributor gets a Medicare number, he or she will be reimbursed mechanically by every other insurance corporation, including PPOs and HMOs.  That is very wrong since insurance companies create or develop their own precise policies.  It can then be said that what one company permits, another one might not (Fishman, 2002).

V. Private Insurance

In the United States, there are many private insurance plans that exists. Due to this, the guidelines for advance practice nurses are highly variable. There are times that the plans include the nurse provider in the preferred provider network. But there are also times that the nurse provider is considered outside the preferred provider network. So in general, less coverage is then afforded for the services rendered by nurses. These phenomenal places burden on those who have minimal resources. The number of networks that seeks to include practitioners among their credential providers is increasing.

When discussing about the reimbursement issues, the fact that advance practice nurses always receives less payment that physicians arises. Advance practice nurses have been taught how to provide high quality care which is equal to the care provided by physicians. Because of this, they should be paid an equitable fee for the services they have rendered. Efforts are now exerted in order to fix these inequities. (Lundy)

VI. Why APNs Do Not Receive Equal Reimbursement

The Medicare Payment Advisory Commission or MedPAC examined the payments differencials between the clinicians and physicians. Why does this two groups do not get equal reimbursements? The MedPAC conjured that there is actually no analytical foundation that can support this. So in order to answer this question, the Commission investigated if these two groups, ‘physicians’ and ‘non-physician providers’ produces the same products or different products.

According to the Commission, the Medicare must set the service payment equal to the cost incurred in efficiently rendering the service. Whenever the physicians and clinicians have provided the same service, then the payment for the low cost provider must be applied for all service providers. In many cases, there are many distinguishable differences between the services rendered by physicians and clinicians. Citing an example, according to reimbursement data, clinicians who are not physicians demonstrates a less complex evaluation and management services than physicians. Other specializations and surgical services are not included in the scope of practice of certain clinicians. Adjustments and changes for these types of billing codes include differences in resource costs.

Since the nature of billing codes is imprecise, the Center for Medicare and Medicaid Services were not able to distinguish the different categories of clinician who provide similar services. They have this assumption that physicians are much prepared to diagnose and treat patients that have severe illnesses.

But, contrary to this, anecdotal reports stated that other clinician sometimes spend more times in checking and treating patients with severe illnesses or who are in critical conditions, which made the physicians to care for a greater number of patients with lower acuity. Whenever a physician and other clinician bill for the same service, it is very difficult to tell of the physician saw a more complex patient. Due to these uncertainties in comparing their services, the Commission is reluctant in altering the payment differential.

And certain policies even on the same company might be allowed in one state but not in another state.  As point of the matter, if one company has three product lines such as HMO, fee-for-service or indemnity, and PPO, then it may also have three dissimilar guiding principles for nurse practitioners (Bardach, 2006).

Consecutively, to ultimately become a credentialed contributor for each insurance plan that patients are secured with, a nurse practitioner must then submit an application for provider category with each and every insurance company, including Medicare and Medicaid.

From that discussion, every provider must be familiar with some fundamentals about Medicare. First and foremost, there is Medicare Part A, which actually covers skilled nursing home, hospital, and home health charges; and then there is Medicare Part B, which then envelops most outpatient services, the care patients in particular obtain from “doctor’s offices” (Fishman, 2002).

When it comes to the ‘incident to’ billing, the Commission decided to consider that services rendered by clinicians who are not physicians but billed as ‘incident to’ must be paid 100% of the physician fee schedule. The Commission have stated that the incident care fee is predicated upon the care or service provided by the team, with the non-physician giving the direct patient care services and the physician taking responsibility to the over-all welfare of the patient. They concluded that the team approach to care provides value which warrants payment at the full rate. (Edmunds, 2002)

V. Conclusion

Reimbursement issues have become challenge to nursing practitioners. Among the critical areas that NP should know are the following: the reimbursement process, contracts and the documents required. They are expected to take possession and responsibility of the procedure on the reimbursement. The APNs should first begin with comprehending their involvement contracts with health care plans. Secondly, nurse practitioners should become familiar with various requirements when it comes to documentation to sustain appropriate CPT coding. APNs should responsibly scrutinize an illustration of their assortments against their monthly charges.

VI. Preparing for Future APN Reimbursement

Being part of the healthcare system, Advance Practice Nurses (APNs) continue to search for greater quality, effectiveness and effeciency in delivering care. Many organizations and institutions like Center for Medicare and Medicaid Services (CMS) are taking the lead in identifying and validating indicators of high quality health care aiming to streamline delivery of care and to reduce convulated health care costs.

• Composite Measures – a reimbursement coding category that is currently being validated to deliver quality measures which can lead to desired patient results for chosen chronic diseases or conditions. (Kennerly, 2007)

Establishing these new standards are based on the assumptions that by using them will cause a consistent high quality of outcome for the majority of patients and there will a great decrease in health care cost. The CMS is currently focusing on reforming quality reimbursement sytems which can save money while rewarding those care providers for their quality performance.

• Pay-for-Performance led to determining the importance of implementing a common set of clinical standards for medical care. This means a provider’s performance and reimbursement is now and in the future will depend on and be judge against a national standard for care rather that past provider;s performances. (Kennerly, 2007)




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