History – Reimbursement

By Diane Walker, RN, MSN, FNP-BC and Lynn Poole, RN, FNP-BC

Medicare: HR 258 introduced in January, 1997 “to amend the Social Security Act to provide for mandatory coverage of services furnished by nurse practitioners and clinical nurse specialists under State Medicaid plans.”

Medicare: HR 893 introduced on February, 1997 “to provide for increased Medicare reimbursement for nurse practitioners and clinical nurse specialists to increase the delivery of health services in health professional shortage areas, and for other purposes.” Reimbursement was set at 85% of the physician rate, where it remains today.

July, 1997: Psychiatric Mental Health CNS plan to seek Medicaid reimbursement.

July, 1998: A large payer made a decision to decrease the payment rate significantly for the services provided by NP’s. Working closely with other stakeholders, VCNP educated the payer about the impact on the access to care and satisfaction of their beneficiaries and eventually were successful in convincing the payer to continue payment at the prior rate.

VCNP Reimbursement Task Force

2002: VCNP Reimbursement Task Force was formed primarily to address Medicaid reimbursement for all classes of NPs (not just PNPs, FNPs and CNMs) and to develop a strategy for working with payers to obtain direct reimbursement for NP services. NP representatives on the task force included mental health, family, adult, women’s health, geriatric, CRNA and CNM.

Medicaid – the Task force devoted a majority of the time to the development of a strategy to support the need for an administrative change within DMAS for reimbursement for all classes of NPs rather than pursuing a legislative strategy. At that time, it was felt that the DMAS environment was NP friendly and may be open to this idea. However due to budget constraints and changes within the administration, the proposed changes did not move forward.

Other payers – some work was done on the development of a strategy for a marketing approach to payers other than Medicaid and Medicare. One confounding factor was the inability to identify payers within the Commonwealth who were already or might be willing to contract directly with NPs. Requests were made to the VCNP Regions to help identify those payers but little information was forthcoming.

2004: Once the expansion of Medicaid reimbursement seemed no longer to be a viable option, the task force disbanded without further action, activity or recommendations.

Multi-state Reimbursement Alliance (MSRA)

In 2006, Virginia was invited to participate with other states in the formation of the MRSA. The MSRA aims to seek solutions to ensure reimbursement parity for APNs. As of 2009, there are ten states included in the Alliance: Ohio, Michigan, Indiana, Illinois, Pennsylvania, Virginia, West Virginia, Kentucky, Minnesota, and Washington State. The goals of the group are as follows:

  • To utilize the legal, legislative and regulatory mechanisms needed to overcome the reimbursement barriers facing APN’s.
  • To provide state and regional perspectives on the problems commercial payers create for APN providers due to inconsistencies in payment for services rendered.
  • To assure that fair and equitable reimbursement is guaranteed to all APN’s in the Multi-state geographic area
  • To assure that patient access to APN services is not limited, restricted, or denied due to commercial payer rules and regulations.

The first year, a survey was conducted to assess the reimbursement problems that APN’s were confronted with. There were nine states that participated, with a total of 1508 respondents. In Virginia, there were 179 respondents. The survey revealed that most APN’s were not well informed on payment issues within their own practices.

The MSRA holds an annual conference for the purpose of informational and educational exchanges. Diane Walker represented Virginia for the first two years in attending the conference. Joanne Iannito plans to attend the fourth conference in 2009.

Virginia Reimbursement Task Force

The membership in the MSRA sparked the formation of the reimbursement task force within Virginia. Several teleconferences were held. Members of the Reimbursement Committee, a subcommittee of the Government Relations Committee, were Diane Walker, Lynn Poole, Louise Pesniak, and Isabelle Amann.

The focus of the discussion was identification of the many complex issues surrounding reimbursement. It was recognized that there seemed to be limited interest in the issue among NPs in VA, as many practices continued to bill for NP services “incident to” the physician services. The task force felt it important to make reimbursement part of the ongoing educational efforts and to include this as a topic at the VCNP annual conference. As NP’s continue to make strides in reimbursement, challenges related to scope of practice may emerge as a result. As health care shortages grow, NPs need to be well educated to protect the financial health of the profession and their individual practice. Data is needed to present to payers representing NPs as a solution to access to care in VA. An additional factor was the emergence of the convenient care industry into Virginia, resulting in contracts being negotiated nationally without consideration of NPs in other practice settings.

2007: The leadership of the task force was transitioned from Diane Walker to Lynn Poole as a sub-group of the VCNP Government Relations Committee.

2007: Reimbursement Task Force – comprised of VCNP members from around the state interested in and knowledgeable of varying reimbursement issues in the Commonwealth including: Ashley Cole, Diane Walker, Isabele Amann, Joanne Iannitto, Lynn Poole (Chair), Marsha Green, Mary Duggan, Michele Satterlund, Pete Hill, Lee Demko

2008: VCNP representation to the MSRA transitioned to Joanne Iannitto

2008: Medicaid made an administrative change allowing all NPs in VA status as Medicaid providers at a reimbursement rate of 100% (exception is those in mental heath)

2008: Membership polled to identify barriers to NP practice revealed issues related to reimbursement. Some were based on fact, others were based on misconceptions, lack of clarity or a poor understanding of their practice’s billing and collection procedures.

2008: The task force identified the following reimbursement issues:

  • NPs lack of understanding of Medicare and Medicaid billing practices
  • Ongoing confusion related to “Incident To” billing
  • Policies for inclusion of NPs as providers vary among Commercial payers
  • Many NPs lack understanding of the billing and collections processes within their practice
  • Effect of “convenient care clinics” on current and future reimbursement environment
  • Possibility of encountering Medicaid issues with the addition of all classes of NPs to Medicaid provider panel Task Force areas of focus

Task force areas of focus:

  • Identify issues that need clarification/education versus specific action
  • Ongoing education of NPs
  • Develop strategies to market NP services to payers
  • Conduct routine teleconferences to explore issues and options
  • Monitor changes in healthcare environment and identify areas where VCNP can/should have a voice