The Nurse Practitioner · 1998 · 15 citations · 0 references
Health ProfessionsHealth PolicyHealth Services AdministrationHealth InsuranceHealthcare PolicyManaged CareMedical BillingProvider ContractingProvider Payment PolicyProvider ReimbursementReimbursement PolicyReimbursement RegulationBillingManaged Care OrganizationsProvider Reimbursement ArrangementsProvider RelationshipsRegulation Of Medical PracticeReimbursement MechanismsReimbursement SystemsThird-party Payer Reimbursement
Reimbursement policies of third‑party payers determine whether nurse practitioners can continue providing care, with Medicare, Medicaid, indemnity insurers, and managed care organizations each having distinct fee schedules and legal frameworks. The article aims to equip stakeholders with essential information for discussing NP reimbursement mechanisms and challenges. It explains how to establish provider relationships, submit claims, and address reimbursement denials. Some payers now reimburse NPs directly, either independently of physician practices or under NP‑specific rules.
Whether a nurse practitioner (NP) is employed by a medical practice or is self-employed, the reimbursement policies of third-party payers will determine whether an NP continues to provide care on a long-term basis. The payers--Medicare, Medicaid, indemnity insurers, and managed care organizations--each have their own reimbursement policies and fee schedules, and each operates under a separate body of law. Some payers have a history of reimbursing for NP services in the same manner as they reimburse for physician services. On the other hand, some payers have recently begun to reimburse NPs directly, either as separate and apart from an employment relationship with a physician practice or following NP-specific rules and policies regarding reimbursement. This article offers basic information necessary to communicate with practice managers, billing experts, and the payers about reimbursement mechanisms and problems. It covers how to set up provider relationships with the various payers, how to submit bills, and how to deal with denial of reimbursement when it occurs.