NURS 6565: Synthesis in Advanced Practice Care of Complex Patients in Primary Care Settings | Week 8

You are now approaching graduation, your clinical exposure has allowed you to better understand the coding and billing process. An essential element in clinical practice will be reimbursement. All NPs must give due diligence and ensure all services provided are accurately coded and billed appropriately. Avoiding fraudulent billing is a key element to your success as an NP. As providers, we are ultimately responsible for billing that occurs with our assigned Medicare, Medicaid, and other third party reimbursement entities’ assigned numbers.

This week you will focus on understanding the differences in levels of billing and the importance of coding accurately. Additionally, billing barriers, which inhibit independent practice, and how this impacts your decision on relocating to an alternate state to have independent practice will be reviewed.

Learning Objectives

By the end of this week, students will:

• Analyze reimbursement issues
• Compare the impact of reimbursement issues between collaborative practice and independent practice
• Analyze ethical and legal implications of reimbursement issues

Learning Resources

This page contains the Learning Resources for this module. Be sure to scroll down the page to see all of this module’s assigned Learning Resources.

Required Readings

Buppert, C. (2018). Nurse practitioner’s business practice and legal guide (6th ed.). Sudbury, MA: Bartlett & Jones Learning.

• Chapter 9, “Reimbursement for Nurse Practitioner Services” (pp. 311-325)

Discussion: Reimbursement Issues for Nurse Practitioners

Understanding the complex process of accurate coding and billing is essential to a sustainable practice. As NPs, we are ultimately responsible for ensuring all coding and billing is accurate for each patient seen. For this Discussion, you will search the health care literature and summarize a peer-reviewed journal article published within the last five years.

To prepare:

• Select one of the following topics:
  • Applying for Medicare and Medicaid Provider Numbers
  • Application process for National Provider Identifier Number
  • Incident to billing
  • Coding-Evaluation & Management
  • Fraudulent billing
  • Billing Self-Pay patients
  • Managed Care Organizations
• Conduct a search and select a peer-reviewed journal article published within the last five years related to the topic you selected.

Note: For this Discussion, all students are to avoid all written work, which reviews or outlines coding and billing at previous or current worksites as well as previous or current practicum sites.

By Day 3

Post a brief summary of the article you selected. Include the key reimbursement issue addressed and how they would impact the NP in a collaborative practice versus and independent practice. Discuss an ethical or legal implication(s) associated with your article.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days by providing a comparison between the article you selected and the article that your colleague selected

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Discussion: Reimbursement Issues for Nurse Practitioners

ADDITIONAL INFORMATION;

Discuss reimbursement issues for nurse practitioners

Introduction

Nurse practitioners are less likely than physicians to be paid fairly for their work. That’s because they’re often not reimbursed by public and private health care payers, who don’t know or understand the difference between a nurse practitioner and physician. In this post, I’ll explain how reimbursement works for nurse practitioners and what you can do to help ensure they get paid fairly for their services.

State laws

State laws vary. Some states allow nurse practitioners to practice independently and some require that they work under the supervision of a doctor. Some states allow nurse practitioners to prescribe medication, while others require them to follow the same guidelines as physicians when prescribing drugs. In addition, some states allow nurses with advanced training in various medical specialties (such as neonatal care) and surgical skills (including board certification) who are certified by the American Board of Medical Specialties (ABMS) or American Osteopathic Association Board Certification Program (AOABCP), respectively,

to perform minor surgeries such as sutures or incisions without having received additional training from anesthesiologists or orthopedic surgeons; however these individuals do not have full control over this type of procedure because it requires additional training from experienced staff members who are supervised by more experienced doctors in order for them to feel safe performing such procedures on patients without any complications occurring during surgery itself.”

Some states give nurse practitioners more autonomy than others.

As a nurse practitioner, your job is to provide care to patients and their families. You can play an important role in helping people manage the symptoms of illness, but it’s also important that you have the resources available to do so effectively.

Some states grant nurse practitioners more autonomy than others—and this can make a difference in how reimbursement works for them. In some states (like California), nurse practitioners are allowed to write prescriptions for controlled substances; in others (like Texas), they may only be able to order tests or draw blood samples without being reimbursed by insurance companies or employers’ plans (though this varies by state).

Licensure

• State laws that regulate nurse practitioners

• Licensure requirements for nurse practitioners

• Differences in licensure requirements between states and countries

Nurse practitioners are typically licensed in one of two ways: by state or by country. While some U.S. states require licensure and others have voluntary registration, most countries have mandatory credentials for nurse practitioners.

Public and private health care payers

Most private health care payers are less likely to reimburse for nurse practitioner services. This is because there is a lack of uniformity in the definition of what constitutes an NPs’ scope of practice, which makes it difficult for them to document their activities and prove that they have done what they have been paid for. In addition, these private insurers require physicians to supervise nurse practitioners rather than allowing them autonomy over patient care decisions or providing adequate oversight through self-governance programs such as those offered by some large insurance companies (e.g., Aetna).

Private insurers also tend not to reimburse providers as much as public ones do when using NPs as primary care providers; this can make it difficult for an NP who works part time or has other jobs outside their regular practice hours because they may not be able to take advantage of benefits available only through employer-based plans (e.g., health insurance).

Medicaid and Medicare

You may be wondering how reimbursement for nurse practitioners varies between Medicaid and Medicare.

Medicaid and Medicare are government-run health insurance programs that cover low-income people. Medicare is for people over 65, while Medicaid is for low-income adults who have little or no income (or who have specific disabilities). Both programs reimburse practitioners based on a fee schedule, which sets rates paid to providers by the government.

Nurse practitioners deserve to be paid fairly for their work.

As a nurse practitioner, you are highly trained and skilled. Since NPs provide a wide range of care, they deserve to be paid fairly for their work.

NPs are licensed to practice in all 50 states, which means that they can provide primary care services to patients of all ages without restrictions or limitations on where they are located. Their education is at the same level as physicians’ education they’re registered nurses who have completed additional training in areas such as pediatrics and obstetrics/gynecology and this provides them with the necessary knowledge base needed for providing quality patient care.

Conclusion

If you are a nurse practitioner, it is important to know the reimbursement issues that may affect your income. If you are not sure how to handle these issues, contact an attorney who specializes in this area of law.