Current APN Issues Regarding Reimbursement

• Direct Medicare Reimbursement for NPs
• Sections of HR2015 Related to Medicare Reimbursement

• January 1998: BBA came into effect; regulations not yet agreed upon by HCFA
• Definition of physician collaboration in BBA: A process in which a nurse practitioner works with a physician to deliver health care services within the scope of practice, with medical direction and appropriate supervision as provided for in jointly developed guidelines or other mechanisms as defined by the state in which services are performed. This is very controversial.
• DILEMMA: equal pay for equal services versus cost savings by having decreased billing rates for APNs compared to physician reimbursement rates.
• Medicare & Medicaid up to now have reimbursed APNs for working with rural or under-served populations
• Policies regarding APN payment by private insurers are contract-specific and vary. Some Third Party Payers reimburse APNs at 100% of the physician rate. Some refuse to reimburse APNs at all.
• APN Medicare billing (Part B) is discounted to 85% of physician fee schedule
• APN reimbursement laws, rules and regulations are different for rural areas:
  - in rural areas NPs can own health care clinics
  - in rural areas NP billings are paid to the clinic, not the provider