Challenges Facing NPs

Nursing Practice is aimed to help to fulfill the growing demands of the patient and shortage of physicians. Research analysis made by Westat (2015) for U.S. Department of Health and Human Services states the statutory scope of practice(SOP) restrictions at the state level, hospital or facility bylaws, and federal regulations and statutes that prevent NPs from accessing or admitting to certain types of health care settings may need to be addressed.

In states with restrictive SOP laws, NPs are legally required to follow a set of protocols under a supervising physician, including requirements for physician signatures, restrictions on prescriptive authority, and strict limits on professional judgment and the degree to which NPs may practice autonomously. The incidence to billing is one of them. The incidence to billing and other restrictions on NPs scope of practice forces the belief that they are lesser providers than a physician.

There are an estimated 234,000 nurse practitioners (NPs) in the United States. Currently, Medicare reimburses NPs at 85 percent of the prevailing rate that a physician would receive when providing the same services. Under incident to billing, a physician, under certain circumstances, is permitted to bill Medicare using their NPI number for services that were actually provided by an NP (or a physician assistant [PA]). This billing rule was initially designed to offset operating costs for physicians working with NPs and PAs to care for Medicare beneficiaries. Although there are many more NPs billing directly using their own NPI, the rule continues to allow for billing of NP visits at the higher physician rate instead of at, the lower NP rate (AAN, 2019).

Results showed that while the vast majority of NPs had their own NPI, 81 percent reported having a practice arrangement with a primary care physician. The survey also found that 29 percent of primary care NPs and 17 percent of primary care physicians reported all services provided by NPs in their practice as being billed to Medicare under a physician’s NPI (Hain and Fleck, 2014).

Implications for Nurse Practitioners

Buerhaus, et al. (2018) state that incident to billing hides the contributions of NPs owing to the physician due to billing for their services. Thus, it misleads the complete data during policy making and negotiating with payers and employers. It also affects the eligible for bonus payments under The Medicare Access and CHIP Reauthorization Act (MACRA). As per MACRA, an NP must submit claims for at least 100 beneficiaries and at least $30,000; if a physician bills for the services provided by the NP, then some NPs could be excluded from the bonus payments.

Several studies suggest NPs’ outcomes are equivalent to, and in some cases better than, primary care physicians at lower costs (Westat,2015). NPs are known to provide a high quality of care at lower costs than physicians, yet have physicians bill for this care as if they provided it and got paid at a higher rate, which causes consternation among many NPs. I believe the practice of incident to billing should again be evaluated which will help to account of the quality and the cost of services provided by NP (Westat. (2015). Impact of State Scope of Practice Laws and Other Factors on the Practice and Supply of Primary Care Nurse Practitioners [PDF]). U.S. Department of Health and Human Services. This information would help both the NP leaders and the payers better formulate policies concerned with NP payment and other policy goals.

References:

Buerhaus, P., Skinner, J., McMichael, B., Auerbach, D., Perloff, J., Staiger, D., & Skinner, L. (2018, January 8). The Integrity Of MACRA May Is Undermined By “Incident To Billing” Coding. Retrieved from https://www.healthaffairs.org/do/10.1377/hblog20180103.135358/full/

Hain, D., ANP, & Fleck, L. M., FAANP. (2014). Barriers to NP Practice that Impact Healthcare Redesign. Barriers to NP Practice, 19.

Impact of State Scope of Practice Laws and Other Factors on the Practice and Supply of Primary Care Nurse Practitioners [PDF]. (2015). Rockville, Maryland: Westat An Employee-Owned Research Corporation®.

Multistate Reimbursement Alliance (MSRA). (2019). Retrieved from https://www.aanp.org/practice/practice-management/business-resources-for-nurse-practitioners/multistate-reimbursement-alliance-msra

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