The growth and sustainability of nurse practitioners requires transparent, fair, and equitable reimbursement policies. Complicating this issue is variation in reimbursement policy within and across federal, state, and other payers.
Reimbursement for Medicare the nurse practitioner must use their own National Provider Identifier number (NPI) to get direct reimbursement of 85% of the physician fee schedule. If the physician bills for the services of an ARPN, it is called “incident to billing”and Medicare pays at 100%. “Incident to billing” means the services provided must be under the direct supervision of the physician, the physician initiates the course of treatment, and the physician must provide subsequent services of sufficient frequency to reflect active participation in managing the course of treatment. Incident to billing is a barrier causing the APRN to be hidden by not billing under their NPI number. All data metrics are extracted by using NPI numbers for reports showing cost and quality care. If APRN are not direct billing under their NPI number, we are unable to show our worth.
Various agencies are working to end incident-to billing. “They include the Medicare Payment Advisory Commission (MedPAC), an independent agency established to advise Congress on issues affecting the Medicare program (MedPAC, 2019), and the American Association of Nurse Practitioners (AANP). MedPAC and AANP advise APRNs to bill directly for services provided and recommend the abolishment of incident-to billing” (AANP, 2017).
APRN’s reimbursement for Medicaid are made at the state rather than federal level. Whereas Medicare reimbursements rate are decided on the federal level. Medicaid are decided by the state and APRN’s are reimbursed anywhere from 70% to 100% of the physician fee schedule.(Buppert, 2020). This means that unlike Medicare, some state Medicaid plans treat services provided by nurse practitioners equally to those provided by physicians. In fact, most states reimburse NPs at 100% the rate of MDs. The barrier for APRN’s is that each state can regulate the reimbursement fee based on the nursing practice act for that state. In a systematic review by (Harkless, 2018) concluded that each Medicaid state reimbursed based on scope of practice legislation, which shapes NP clinical practice. The fact that APRN’s can bill under their NPI number provides the opportunity to gather evidence-based metrics to show improved patient outcomes for state laws and policies.
Private health plans or fee for service plans reimbursement is dependent on the carrier and the state The APRN should contact each carrier for information pertaining to credentialing and reimbursement. The barrier is the companies can choose to reimburse or not reimburse direct billing for the APRN.
Managed Care Organizations are organizations that offer medical services through their own networks of doctors and hospitals. The payment system is through prepaid member fees, limiting provider reimbursement at a fixed rate. APRN’s will need to check with each organization for credentialing and reimbursement.
A major barrier is, by APRN’s billing for direct services, healthcare facilities and physician offices will not be able to receive full reimbursement, which will impact the facilities long term bottom line.
Nurse practitioners can assist in overcoming the barriers to reimbursement by understanding the reimbursement process, read and understand the participation contracts, become familiar with various requirements when it comes to documentation for appropriate CPT coding, be involved at the policy level to assist in creating change. A simple way to influence change is to be involved in a nurse practitioner organization. APRN’s can write to their states policy representative to influence change.
References
American Association of Nurse Practitioners (2017). Centers for Medicare and Medicaid services: innovation center new direction. Position Statement/Request for Information to CMS. https://storage.aanp.org/www/documents/CMMI-Comments.pdf
Buppert, C. (2020) Nurse Practitioners Business Practice and Legal Guide. 7th Edition. Jones & Bartlet Learning Center. Burlington, MA.
Harkless, Gene & Vece, Loretta. (2018). Systematic review addressing nurse practitioner reimbursement policy: Part one of a four-part series on critical topics identified by the 2015 nurse practitioner research agenda. Journal of the American Association of Nurse Practitioners. 30. 673-682. 10.1097/JXX.0000000000000121.
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