NAPNAP Position Statement on Reimbursement for Nurse Practitioner Services
Article Outline
Nurse practitioners (NPs) provide comprehensive, cost-efficient, high-quality health care services in diverse settings across the care and age continuum. NPs are important members of the health care delivery team, and patient outcomes associated with NP's care have repeatedly been demonstrated to be outstanding (Hauck, 2009, Horrocks et al., 2002, Karlowicz and McMurray, 2000, Kleinpell and Gawlinski, 2005, Varughese et al., 2006). The National Association of Pediatric Nurse Practitioners (NAPNAP) understands the unique contribution that NPs make to the nation's health care system and believes that NPs must receive equitable reimbursement from all payers in order for NPs to provide the communities they serve with the full scope of health care services. Because NPs incur the same overhead costs as physicians in providing care to patients, they should be recognized as independently licensed providers of primary and acute care and therefore must be reimbursed commensurate with physicians for the services they deliver.
While the U.S. Balanced Budget Act of 1997 authorized Medicare reimbursement for NPs in all sites of service, it set the payment rates for NPs at only 85% of the physician rate. State Medicaid programs and many third-party payers, such as commercial indemnity insurers, commercially managed care or health maintenance organizations, and businesses or schools, also frequently pay NPs less than physicians for the provision of the same services (Hansen-Turton, Ritter, & Torgan, 2008). In addition, these various third-party entities have different rules on coverage of NP services or may not recognize and credential NPs who provide vital patient care services. These various limitations on coverage and payment impede the ability of NPs to practice to their fullest potential.
NPs' ability to demonstrate the clinical and financial outcomes related to the care they provide is critical to support changes in coverage and reimbursement rules, yet efforts to document these measures are hindered because third-party payers often require that NP services be billed under a physician-colleague's name and provider number. This practice renders the care provided by NPs invisible. As a consequence, administrative and clinical data regarding NP services are folded into the physicians' information, which makes it difficult to document the exact services rendered by NPs or the revenue generated by them (McCloskey, Grey, Deshefy-Longhi, & Grey, 2003).
NPs who co-manage inpatients with physician-members of their practice face an additional challenge that arises when both the NP and physician evaluate a patient on the same day. Only one claim for the patient evaluation may be submitted from that specialty team. Because the physician rate of reimbursement typically is greater than that of the NP, the physician's service generally is reflected on the claim. Shared billing can help resolve this problem by allowing groups to consider the services of both professionals in determining the level of evaluation and management service to be billed (Kleinpell, French, & Diamond, 2007). Inpatient reimbursement can further be complicated by bundled codes, when many critical care and surgical service charges are bundled into one charge for the patient, making it challenging to decipher the care provided by the NP.
NAPNAP advocates for:
NAPNAP, an organization that promotes optimal health for children, believes that NPs should apply for and use their own provider numbers and that it is imperative that NPs be reimbursed directly and equitably for the health care services they are able to provide.
The National Association of Pediatric Nurse Practitioners would like to acknowledge the contribution of the following NAPNAP members and individuals from the NAPNAP Professional Issues Committee: Andrea Kline, MS, RN, CPNP-AC/PC, FCCM, Professional Issues Chair; Brenda Cowan Frautschy, MSN, RN, APNP, CPNP, CNS; Raechelle Dow, MPH, MSN, CPNP; Madelyn McMurtrie, MSN, CPNP; Ann Sheehan, MA, CPNP; Allison Shuren, JD, MSN; Judy Verger, PhD, PNP-BC; and Heather Keesing, MSN, RN, FNP-BC (Staff).
References
- . Insurers' contracting policies on nurse practitioners as primary care providers: Two years later. Policy, Politics, & Nursing Practice. 2008;9:241–248
- . Expediting care for children: Advanced practice nurses as short stay hospitalists. Nursing Administration Quarterly. 2009;33:67–69
- . Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal. 2002;324:819–823
- . Comparison of neonatal nurse practitioners' and pediatric residents' care of extremely low-birth-weight infants. Archives of Pediatrics & Adolescent Medicine. 2000;154:1123–1126
- . Assessing outcomes in advanced practice nursing practice: The use of quality indicators and evidence-based practice. AACN Clinical Issues. 2005;16:43–57
- . Billing for NP provider services: Updates on coding regulations. The Nurse Practitioner: The American Journal of Primary Health Care. 2007;32:16–17
- . APRN practice patterns in primary care. The Nurse Practitioner: The American Journal of Primary Health Care. 2003;28:39–44
- . NAPNAP position statement on pediatric healthcare/medical home: Key issues on delivery, reimbursement, and leadership. Journal of Pediatric Health Care. 2009;23:23A–24A
- U.S. Balanced Budget Act, 42 U.S.C. §1385l(a)(1)(O) (1997).
- . Impact of a nurse practitioner-assisted perioperative assessment program on quality. Pediatric Anesthesia. 2006;16:723–733
Adopted by the National Association of Pediatric Nurse Practitioners' Executive Board on May 28, 2009. This document replaces the 2004 NAPNAP Position Statement on Reimbursement for Nurse Practitioner Services.
All regular position statements from the National Association of Pediatric Nurse Practitioners automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
Correspondence: NAPNAP National Office, 20 Brace Rd, Suite 200, Cherry Hill, NJ 08034-2633.
PII: S0891-5245(09)00202-8
doi:10.1016/j.pedhc.2009.06.013
