How are APNs reimbursed in these systems?

• "Incident To" Services: APN services performed in conjunction with a physician, which are billed to Medicare under the physician name.
  • Implies that physicians initiate the care, are on-site and are supervising care.
  • Promotes a billing practice that seldom reflects the reality of care delivery.
  • Does not allow APNs to receive credit for the care delivered and does not recognize APNs as PCPs.

• Insurance Conventions: Policies of the insurance agencies in each state related to reimbursement. These vary greatly from one to another.
  
  
• Capitation: Set payment per member per month from third party payer to provider/provider network, which may include APNs.
  
  
• Federally Qualified Health Clinics have specific federal reimbursement policies.
  • Include broad services such as primary care, dental, pharmacy, etc.
  • Reimburse based on actual costs per encounter, which yields 25-50% more revenue than fee-for-service rates of reimbursement.
  • Must employ NPs or PAs 50% of time they are open.
  • Have productivity standards which must be met annually (2100 encounters per year for NPs)

• Health care services must be deemed "medically necessary" in order to be covered for reimbursement," which means ordered by a doctor/APN, required for symptom management, and provided in accordance with approved and generally accepted medical-surgical practice. There is controversy over "medically necessary" definitions between providers, patients and third party payers, particularly for new/experimental treatments and care of people with chronic conditions.
  
  
• Each year, Congress sets a "conversion factor" or a dollar figure used to calculate the funding for each RVU for that year.
  • This information is published annually in the June and November Federal Registers.
  • There is also a geographical correction factor determined for each region of the U.S., which is often subject to controversy and leads to very different Medicare reimbursement amounts from one area of the U.S. to another. Regions such as the Midwest that offer comprehensive services may be penalized for their cost-effectiveness by being assigned low RVUs, thus receiving smaller payments than states with fewer health services.