Reimbursement Entities

Entities which reimburse providers for health care costs include:
    Governmental payers (i.e. Medicare, Medicaid, Champus)
    Non-profit insurance corporations (i.e. Blue-Cross/Blue Shield)
    For-profit insurance corporations (i.e. Aetna, Prudential)
    Self-insuring corporations or coalitions (i.e. union health care plans, Buyers' Health Care Action Group, Dayton-Hudson, etc.)

Entities that provide care may be linked to reimbursement systems, but will be incorporated separately. For example, the federal government provides care in its veterans' hospitals; it pays for care with the Medicare system. HealthSystems Minnesota is a network with a provider arm called the Allina Health System, and a reimbursement system called Medica.

Entities that provide health care are:

  1. Managed care HMO or PPO systems
  2. Private practice systems (have virtually disappeared in Minnesota)
  3. Home health care agencies & public health agencies
  4. Specifically funded health centers (federally funded, such as Community Health Centers, Federal Qualified Health Centers, Migrant Health Clinics, Indian Health clinics, etc)
  5. University teaching hospitals (called academic health centers, largely funded by Medicare $)
  6. Hospitals, nursing homes, skilled nursing facilities
APNs must understand the structure and reimbursement rules and regulations of both the payers and the health care delivery systems in order to negotiate for direct reimbursement. It is important to note: Government payers that reimburse for health care costs, such as Medicare and Medicaid, develop policies, rules and regulations for reimbursing providers. These governmental policies are then used as the standard for reimbursing providers in the other nongovernmental types of systems. Thus APNs must clearly understand Medicare and Medicaid.

Medicare:

Medicare is a senior citizen health care financing program shared between federal and state governments. In the late 1960s, the government saw a need to increase citizens' access to health care. Medicare was created to do this for the elderly.
  • Part A, a "hospital insurance," covers inpatient hospital services, some post-hospital nursing care, some home health care, and is paid for through federal payroll taxes. Nursing services are considered part of the hospital fee, which is regulated by a PPS using DRGs. Some inpatient services can be bundled into the DRG, though physician services are separately charged. APNs cannot bill for their inpatient care under Medicare Part A. Exceptions are made for certified nurse-midwives and certified registered nurse anesthetists.
  • State law determines Medicare Part B reimbursement for APN's and requires physician collaboration
  • Part B, also known as Supplemental Medical Insurance, covers outpatient services of physicians and other selected providers, home health visits, and rural health clinic services, and is paid for from general tax funds and patient premiums. NP's and CNS's can be reimbursed directly. APNs are reimbursed under their own identification numbers at a rate that is 85% of the physician fee. "Incident to" billing is allowed in certain circumstances of APN/MD collaboration and has a 100% rate.
    • Part B also is also a source for funding the education costs of health care providers. In particular, it pays for the training costs of resident physicians in academic health centers.
    • APN's must be authorized to deliver services in the state in which they bill Medicare through a process of credentialling.

    Medicaid:

    Medicaid is a federal program administered by each state that provides coverage to low-income families, the aged, and disabled. Each state establishes its own Medicaid rules under federal guidelines.
    • APN reimbursement was included in OBRA 1989 for Medicaid. Each state specifically defined what APN's can be reimbursed for and the particular rates.
    • Medicaid was formerly a fee-for-service system. However many states are now establishing contracts with managed care entities to care for Medicaid clients. These are called P-MAPs (Prepaid Medical Assistance Plans).
    • Medicaid waivers are federal regulations that require states to provide care for special populations, such as children with special health care needs. For instance, a waiver called the TEFRA Waiver assists some families with the payment of health care costs without means testing or a spend-down of the family resources
    • EPSDT is a federal program that funds preventive health services to low income populations and is administered by each state and county. In Minnesota it is is called the "Child and Teen Check-up Program" and covers wellness checkups to age 21. EPSDT has many required components that must be included for reimbursement to occur, including vision & hearing, developmental assessment and TB testing.




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