Reimbursement: General Information
Reimbursement is a central issue for Advanced Practice Registered Nurses (APRNs). Getting paid for the services an APRN provides is essential to staying in business or staying employed. However, many health care institutions and insurers are caught in a quagmire of policies created only to credential and reimburse physicians. APRNs will not be able to use their full potential to improve health care in this nation until the reimbursement issues are resolved. Part of CNAP’s mission is to help APRNs in Texas get appropriate reimbursement. That effort starts by helping APRNs understand reimbursement basics.
Before addressing any reimbursement quagmire, be sure you can answer the following questions.
- Who is your employer and what cost center pays your salary? This is one factor that will determine if the services you provide are billable. For instance, if your salary and benefits are paid by a hospital, no other entity or individual, including you, can bill for your services unless your salary and benefits have been unbundled from the hospital’s cost report. If the APRN is self-employed, or employed by a physician, physician group or medical school, your services will be reimbursable if it is a covered service that is not a duplicate charge of a service billed by another provider.
- What payers were billed for your services and what type of insurance plan/s did your patients have? The route to reimbursement will be different depending on whether the payer is a state program such as Medicaid, a federal program such as Medicare, or private such as Blue Cross and Blue Shield. The type of insurance plan is also a big factor. Because APRNs are included in 1451, Insurance Code, if the patient is covered by a traditional indemnity plan in Texas, the insurer must reimburse for any service you provide that is within the scope of your practice. However, most insurance plans today are managed care plans and many require you to be listed as a provider in order to be reimbursed. Based on HB 2845 (Acts of the 75th Texas Legislature), HMOs and PPOs cannot refuse to list you as a provider if you have gone through the proper steps and your collaborating physician is on the plan and requests that you also become a provider (see §843.312 and §1301.052, Insurance Code). Sometimes the insurance company is simply acting as the plan administrator for a self-insured employer known as an ERISA plan. In that case, the health insurance plan may be exempt from state law and that employer may legally refuse to include APRNs in their plans. Read about ERISA.
- Were you credentialed as a provider on the plan at the time the service was provided? This is a common reason to deny a claim. The date of service is a very important factor if you are a new provider on the plan.
- Is there an alternative way to bill for the service you provided? Just because you were not a provider on the plan on the date of service, does not mean there is no hope to receive payment through another mechanism. In many instances, it is legal to bill the service under the collaborating physician’s name. Exceptions to this could include Medicare billing or instances in which the employer signed a contract limiting service providers to physicians.
- Do you need documentation? If someone is telling you that you cannot be credentialed or reimbursed because of a particular policy or rule, ask to see that information. There are several nice ways to ask for verification. For instance, “My medical director needs a copy of that.” It is also helpful to document the name, job title and telephone number of persons with whom you speak. Doing your homework will help cut the red tape, and may help you avoid being caught in a reimbursement quagmire that threatens your livelihood.
For more information on reimbursement, Carolyn Buppert has a series of excellent articles available on the Medscape web site. These articles contain a great deal of the information one needs for billing most insurance plans for services in various settings. This section also has information about the Texas Medicaid program and other plans administered by the state of Texas. Those state programs have rules that often differ from federal programs, such as Medicare.