|
Q:
Can you give me some direction on billing for Advanced Practice
Nurse services?
A: Many APNs erroneously assume that getting an APN license
removes all barriers to getting their services reimbursed
by insurance companies. Obviously, the goal is "direct
reimbursement"; that is, being able to bill in the APN's
name. There is no question that billing under a physician's
name simply perpetuates the invisibility of APNs. Direct reimbursement
requires APNs being accorded some sort of provider status
by a reimburser. For Medicare, the process involves getting
a Provider Identification Number (PIN), which is in the process
of transitioning to the National Provider Identifier (NPI).
It should be noted that Medicare was issuing PINs to Illinois
APNs a full two years before the APN rules for our practice
act were written. And Medicaid in Illinois was willing to
directly reimburse some APNs even before Medicare, albeit
at a low rate.
The first concept that must be understood is that Medicare
and Medicaid are not the same thing. Medicare
is a program created for the elderly (over age 65) and some
people who are permanently disabled. It is a federal
program regulated through the Social Security Act, and thus
dependent on laws enacted by the U.S. Congress and rules generated
by the U.S. Department of Health and Human Services. Medicaid,
on the other hand, is a program for the indigent, and its
funding is shared between the federal government and
each individual state government. In general, the laws/rules
governing Medicare are the same from state to state. Medicaid
benefits, however, vary tremendously from state to state,
due to the fact that state governments must contribute to
the funding of the program, which gives them some say in how
their money is being spent. While there are some basic services
that all states are expected to provide Medicaid recipients,
each state is allowed a fair amount of leeway regarding what
additional benefits they may wish to cover. As a result, a
Medicaid program is largely dependent on the legislators and
governmental officials in each state.
Many APNs have heard the adage, "as goes Medicare, so
does everybody else," which has led to the common misconception
that if a provider gets a Medicare PIN, s/he automatically
will be reimbursed by every other insurance company, including
HMOs and PPOs. WRONG! Insurance companies can and do develop
their own policies; what one company allows another one may
not. And what one company allows in one state may not be allowed
in another state. In fact, if one company has three product
lines (fee-for-service, HMO, PPO), it may have three different
policies for APNs, even within the same state. In order to
become a recognized provider for every insurance plan that
your patients have, you have to apply for provider status
with each and every insurance company, including Medicaid.
By the way, this is exactly what physicians have to do. Simply
having a physician license doesn't ensure reimbursement.
Furthermore, even the same product line in the same company
in the same state may have variations. Insurance policies
are actually individual contracts between an insurance company
and an individual or employer. Each employer has the right
to craft a unique contract that stipulates the specific benefit
package available to the employees. If an employer chooses
to be generous, s/he may opt to enhance the basic package
the insurance company offers. In such situations, the employees
may enjoy greater benefits (e.g., home health nursing after
a hospitalization) than other employer groups. On the other
hand, if the employer wishes to control costs, s/he may negotiate
a contact with fewer benefits (e.g., greater restrictions
on the kinds of medications that are covered). You and your
spouse might have insurance cards that look identical. However,
if you work at one place and your spouse works elsewhere,
the scope of benefits provided by your respective policies
can vary immensely.
Medicare Basics
All that being said, since Medicare is such a huge program,
it is helpful to grasp its basics elements. There is Medicare
Part A, which covers hospital, home health/hospice, and skilled
nursing home charges, and Medicare Part B, which covers most
outpatient services, specifically the care patients receive
from "doctor's offices." There is also Medicare
C, Medicare+Choice, which is the managed care option, and
Medicare D, the new drug payment option. The remarks below
refer to only Medicare Part B billing. Furthermore, they do
not apply to federally qualified health centers that
serve Medicare patients.
When it comes to an APN's services, an office practice has
two billing options for Medicare Part B:
1.
An APN's services can be billed under a physician's name,
and Medicare reimburses the practice 100% of whatever Medicare
thinks is "usual and customary." However, if a practice
does choose to bill under a physician's name, the physician
and APN must abide by the "incident to" rules of
which there are three basic criteria:
(a) The physician has to be in the office when the APN renders
care (in the suite of offices, not across the street making
rounds in the hospital!).
(b) The APN cannot see patients new to the practice.
(d) The APN cannot see established patients with a new problem.
The reason for criteria (b) and (c) is that billing under
the physician's name implies that s/he initiates and updates
the patient's plan of care. Sometimes meeting all of the "incident
to" criteria can be logistically difficult. If a physician
has to suddenly leave the office, then the practice can't
bill for the services that the APN renders to Medicare patients
while the physician is absent. And meeting criteria (c) can
be complicated for a busy office, because if a patient comes
for a routine visit (e.g., diabetes monitoring) and suddenly
reveals to the APN that s/he has a new problem (e.g., leg
ulcers), the APN has to pull the physician in to assess--and
chart on--the patient. It is not acceptable for the APN to
perform the entire history and physical, chart on the patient,
and have the physician simply co-sign the APN's charting.
The physician is responsible for personally performing the
necessary components of the history and physical and personally
documenting the care (i.e., the new treatment plan). It is
clear that meeting this expectation can send APNs' and physicians'
schedules into a tailspin if very many patients come to see
the APN for "routine" monitoring and suddenly launch
into a lengthy "Oh, by the way..." mode. One more
thing, neither "incident to" billing nor direct
billing require a physician to co-sign an APN's charting!
2. Alternatively, the APN can obtain her/his own PIN from
Medicare. In Illinois providers obtain Medicare PINs from
Wisconsin Physician Services (WPSIC), the company that serves
as the Medicare carrier for Illinois and some other states.
Billing under the APN's PIN means that the practice gets 85%
of the physician rate, BUT it has the advantage that the incident
rules do NOT apply. Therefore, the physician does not have
to be on site when the APN renders care, the APN can see patients
new to the practice, and the APN can see established patients
with new problems. Some practices express concern about billing
under the APNs' own PINs because of the "loss of 15%."
However, a practice actually can make more money by billing
under the APN's number because:
(a) As noted above, abiding by incident to involves complicated
logistics for the office personnel, and
(b) Since there are no restrictions of the types of patient
an APN can see, there is the possibility that the APN's services
can be billed using higher E/M codes.
Furthermore, since most APNs make less than 85% of a physician's
salary, the practice is still getting a profit from APN visits.
Last, but not least, billing "incident to" exposes
a practice to more frequent and careful audits, since Medicare
is very concerned that practices really do abide by the incident
to rules. This, in turn, carries greater risk of being accused
of Medicare fraud or abuse than billing under the APN's PIN.
Such accusations can lead to a practice having to, minimally,
give money back to Medicare. Furthermore, if the fraud and
abuse is deemed egregious, a practice may be fined--in the
thousands of dollars. Finally, it is theoretically possible
that people in the practice (including clinicians) could go
to jail. Needless to say, a practice should avoid anything
that might indicate fraud and abuse.
By the way, Medicare does allow physician assistants (PAs)
to get their own PINs and the rules described above also apply
to them However, the Illinois PA practice act stipulates that
payment for PA services "shall be made to his or her
employer...." This is because PAs are "supervised"
by physicians, versus the collaborative arrangement that APNs
have with physicians. This is just one of several differences
between APN and PA practice in Illinois and in other states.
Information on applying for a Medicare PIN can be obtained
from the Wisconsin Physician Services at www.wpsic.com.
Click on "Providers" on the home page, then surf
through the various links on the "Providers" page.
As noted above, we are now in the transition period regarding
applying for the National Provider Identifier (NPI). If you
already have a Medicare PIN, Eventually, your individual NPI
will be the only number that you will need for billing across
all insurance companies.
Medicaid
Basics
Illinois Medicaid, on the other hand, does NOT require that
practices abide by incident to rules, and it had been very
common to bill for APN services under the physician's name,
even if the physician is rarely on site where the APN renders
care. For years APNs had been able to get their own Medicaid
PINs; however, the policy had been that they could reimbursed
only 70% of the physician's rate, so very few Illinois APNs
had bothered to do this. (Note: This 70% reimbursement did
not apply to federally-qualified health centers.)
However, as a result of negotiation in 2005 between ISAPN
and the Illinois Department of Healthcare and Family Services
in (formerly the Illinois Department of Public Aid), these
rules were changed, so that as of January 1, 2006, APNs will
be reimbursed at the same rate as physicians. There are other
positive changes include. For example, prior to January 1,
2006, Illinois Medicaid reimbursement had been limited to
only certified registered nurse anesthetists (CRNAs), certified
nurse midwives (CNMs), family nurse practitioners (FNPs),
and pediatric nurse practitioners (PNPs). In other words,
the whole host of other NP specialties were not allowed to
obtain Medicaid PINs. Furthermore, the Medicaid "enhanced
rate" (higher than the typical 100% rate) that has been
available to certain physicians who offer maternal-child services
had not been available to APN who render the same services.
Thankfully, these three reimbursement discrepancies were eliminated
as of January 1, 2006, so APNs with their own PINS will be
reimbursed at 100% of the physician rate, all types of APNs
(including all NP specialties) will be eligible for direct
reimbursement, and some APNs will be eligible for the enhanced
maternal-child rate. Unfortunately, there is one category
of Medicaid reimbursement that will remain unavailable to
APNs; namely, certain psychiatric services, specifically those
that are described as "psychotherapy," covered under
the CPT codes of 90804 thru 90899. Such services must be performed
and billed by only a physician, which means that psychologists
and social workers can't bill for these services either.
BlueCross BlueShield of Illinois
Although the BlueCross BlueShield of Illinois (BCBSIL) PPO
has been reimbursing CRNAs and CNMs for their services for
several years, NPs and CNSs had not been accorded the same
benefits. However, as of November 1, 2005, that situation
was finally changed and NPs and CNSs were added to the PPO
Network. The caveat to that November 1 date is that NP and
CNS specialties will be added upon group renewal, meaning
as employer groups renew their contracts with BCBSIL. And
as noted above, it is important to understand that BCBSIL
employer contracts are not identical. Employer groups may
negotiate enhancements or limitations in benefits based on
the premiums they are willing to pay. The only way to know
for sure what the unique benefits are for an employer group
is to review the employee handbook, call the member services
number listed on the back of one's BCBSIL card, or review
the policy and/or contract written specifically for that employer
group.
Any
APN, regardless of specialty, who enters a contract with BCBSIL
(i.e., to be reimbursed in his/her own name) will receive
85% of the rate that physicians receive. That percentage is
identical to the rate that Medicare offers-however, this is
where similarity between the BCBSIL and Medicare ends. If
an APN is employed by a physician or physicians' group and
that practice wishes to continue to bill under a physician's
name, the practice may do so-and the reimbursement
rate will remain at the 100% level. Furthermore, BCBSIL does
not have the equivalent of Medicare's "incident to"
rule. In other words, a practice may bill for an APN's services
even if the physician is not on site when the care is rendered.
Furthermore, unlike Medicare, BCBSIL does not restrict APNs
from seeing patients new to a practice or established patients
with new problems. Therefore, APNs who do not intend to bill
on their own should not apply to participate in the PPO network.
A major advantage, however, of APNs becoming contracted providers
is that their name and practice site will appear in the list
of providers that BCBSIL issues its insured members, which
is enormously helpful if a patient is seeking the care of
an APN.
Joining
the PPO network requires completing a contract with BCBSIL.
As a result of years of discussion with BCBSIL, many NPs and
CNSs may have already received and returned such contracts.
However, given that BCBSIL has been working off a list developed
several years ago, it is likely that circumstances have changed
for many APNs, including the fact that a number of APNs have
obtained licensure during that time. Therefore, any APN wishing
to enroll as a provider in the BCBSIL PPO Network can obtain
an application at www.bcbsil.com.
Click on the "Provider" link at the top of the homepage;
then click on "Request a Contract Application" on
the left frame of the provider page. Clicking on "Forms"
in that same frame will take you to the fee schedule. Take
85% of those fees to determine the rate for APNs. Providers
may also seek assistance via the Providers' Telecommunications
umber, 800-972-8088.
BlueCross BlueShield of Illinois has stipulated certain criteria
for "assistant at surgery" APNs regarding reimbursement.
The plan has extended "assistant at surgery" benefits
to the following allied health practitioners:
-
Certified Nurse Practitioners (CNPs)
- Clinical
Nurse Specialists (CNSs)
- Physician
Assistants (PAs)
To
ensure appropriateness of care, coverage for assistant surgery
is limited to the following criteria:
-
Services performed must be defined by the BCBSIL contract
as eligible for assist-at-surgery
- Services
rendered must be performed in a state-licensed hospital
or ambulatory surgery center
Assistant
surgery claims for a CNPs, CNSs or PAs must be submitted under
the provider number of a contracted BCBSIL physician, physician
group, podiatrist or dentist. Charges for assistant at surgery
services must be reported with the HCPCS Assistant at Surgery
(AS) Modifier.
Everybody Else
As said above, there are no standard rules for private insurers
(indemnity plans, PPOs, HMOs). Any insurance company can establish
its own policies. Many insurers are "silent" on
the issue of APNs rendering care and billing under the physician's
name. The only way to know what the policies of all the different
insurers are is to read their respective policy manuals. Bear
in mind that if you call insurers to ask what their policies
are, the person who answers the phone may not have the proper
information. Indeed, the terms "advanced practice nurse",
"nurse practitioner", etc. are still foreign to
many people, even in the insurance world. Therefore, be prepared
to be bounced around from department to department and to
have to leave a lot of messages, since invariably the person
you need to talk to won't be sitting at his/her desk. In any
case, if you don't like the answer you get on the telephone,
don't be afraid to ask to speak to someone else higher in
the organizational hierarchy.
Being informed about reimbursement is the responsibility of
every single APN. You can NOT let others in your practice
(e.g., billing clerks and office managers, etc.) be the experts
in APN reimbursement. If you want to be marketable it is up
to you to know the policies, rules, and regulations that affect
your practice. Listed below are some other sources of information:
1. There are two excellent books on reimbursement by Sheila
Abood and David Keepnews: Understanding Payment for Advanced
Practice Nursing Services: Volume One: Medicare Reimbursement
(2000) and Understanding Payment for Advanced Practice Nursing
Services, Volume 2: Fraud and Abuse (2003). Both books
can be bought from the ANA publications web site at: www.nursingworld.org.
Click on "Publications" on the left frame of the
home page.
2. Another outstanding summary of reimbursement is provided
by Carolyn Buppert, NP, JD, at www.medscape.com:
--Find the box: "Profession Sites"
--Click on "Nurses", which takes you to the "Nurses"
home page.
--Scroll down to: "Editor's Choice"; "Billing
for Nurse Practitioner Services: Guidelines for NPs, Physicians,
Employers, and Insurers. This link goes for several screens,
but it pretty much sums up the reimbursement issues.
3. For ongoing updates about "non-physician" reimbursement,
there is a newsletter that you or your practice can subscribe
to. It's called Non-Physician Practitioner News. Subscription
information is available at www.decisionhealth.com
or by calling (877) 602-3835. You can get the subscription
both by snail mail and/or e-mail. There's also a way to get
access to back issues online, which is VERY useful. Furthermore,
subscribing to the newsletter allows you to sign up for a
listserv, which is an excellent way to pose specific questions
about billing--especially if the newsletter provides information
that may be subject to regional variations. If you are able
to persuade your practice to pay for the subscription, so
much the better. However, this newsletter provides information
that every APN should want to have access to, even if it means
paying out-of-pocket. Subscription prices vary. From time
to time, Decision Health runs "specials" by offering
a discount for those with professional memberships, and ISAPN
has been included in those time-sensitive specials.
Please note that the current web address for the Illinois
Department of Professional Regulation is: www.ildfpr.com
(yes, that's ".com," not ".gov"). This
is the web site where you can download your practice act and
that of many other professions (e.g., physicians, physician
assistants, physical therapist, etc.). It's also your resource
for information about license renewal, controlled substance
licenses and other regulatory issues. Be sure to mark it as
a favorite on your web browsers!
Updated
February, 2006
|
