Reimbursement Issues for Clinical Nurse Specialists in Ohio - Research Paper Example

running head: Reimbursement Issues For The Clinical Nurse Specialists In Ohio Reimbursement Issues for Clinical Nurse Specialists In Ohio Medicare, Medicaid & Third Party Payments Student’s Name [Pick the date] Contents Introduction 3 Changing Trends in Hospital Reimbursement 4 Difficulties Faced in Reimbursements 5 Legal Status of APNs in Ohio 8 Conclusion & Recommendations 9 References 12 Introduction In United States, development of Advanced Practice Nurses began in rural areas where the strength of doctors was comparatively less. Hence, nursing practitioners had more opportunity to extend the scope of their practice. In 1990s, a decreasing trend towards general practice and primary care was observed in physicians. Major causes of such diversion were the differences in payment structure between general physicians and specialists. As a result, development and extension in the role of advanced practice nurses were observed. Following this trend, recognition of APNs in the state laws was observed which lead to further development of reimbursement policies. In 1989, Omnibus Budget Reconciliation Act was the first step towards direct reimbursements to Advanced Practice Nurses. Before that, APNs paid for services concurrent with those charged by physicians. Recognition of APNs namely Clinical Nurse Specialists by commercial payers, third parties and federal programs such as Medicare and Medicaid asserted that clear guidelines should be provided regarding the payment of services provided by CNSs. As of now, in most cases, CNSs are paid according to physicians’ rates as a fee for their services. However, enhancement in payment structure and ambiguity in state laws about it has given rise to issues regarding reimbursements to CNSs. With increasing healthcare costs, US government has altered its policies in terms of aid given to hospitals which has affected the reimbursements paid to CNSs directly. According to Delamaire and Lafortune (2010), “the development of group practices in primary care also provided financial incentives to employ “intermediate” health practitioners such as advanced practice nurses to contain costs and increase profit margins.” Variations in state laws have given rise to confusion in terms of reimbursement policies. With decreasing hospital funding and vague reimbursement policies, many services offered by CNSs remain unrecognized. Furthermore, collaborative agreements with physicians make APNs role rather invisible in healthcare settings and surveys due to which no major policies can be devised for securing better reimbursement for them. Changing Trends in Hospital Reimbursement Reimbursement of Medicare and Medicaid services is a complex procedure that involves many legislations and regulations. It can be seen that nurses in several states including Ohio have a limited legal authority to claim for reimbursement independently and have their payment mechanism attached to other processes like physician payment system. With increasing emphasis of US government on lessening national healthcare expenses, it is becoming more difficult for advanced practices nurses to receive substantial payments for their services. Furthermore, with shift from hospital’s cost-based system which allowed these institutions to charge government for the expenses they incurred to prospective payment system, hospitals are only receiving partial payments for outpatient procedures only. The resultant effect has been transferred to APNs as well. Dependency on diagnostic related groups and patients’ condition is the main criteria on which these amounts are calculated. Same is the case for Medicaid reimbursements as well (Buppert, 2005). Where Medicaid is a support program run by states independently, most of the states including Ohio follow regime of outpatient services. Therefore, dependent on the condition and level of service provided i.e. routine checkup, surgery etc, hospitals are reimbursed. Reductions in residence services programs and government aid has affected overall hospital budgets and the outcome is deductions in amounts paid to APNs. Hence, the hospitals are forced to cover the amounts paid to APNs and other staff through the amount received under DRG regime. Other than government, third-party commercial payers also pay fixed amounts to hospitals for hospitalization and outpatient services. Therefore, they cannot be charged extra (Buppert, 2005). Difficulties Faced in Reimbursements Where Advanced practices nurses can be hired on third party contracts and can be paid for their services, private nurses as well as hospital employees sustain deduction in their reimbursements due to policies of their employers. Hospitals usually charge third parties for the services of actual medical practitioners i.e. physicians, surgeons etc. Therefore, due to per day payment mechanism, APNs are often found sharing their bills with other physicians. APNs also provide services that are not covered in regime that is eligible for billing. On the other hand, commercial third party payers pay varied amounts for APN services therefore billed amounts may vary. Where according to the policies, “Medicare will pay only one charge per day, per patient, per specialty, for Evaluation and Management billing” APNs are often found providing multiple services that cannot be charged on the same day or they may be part of bundled services that do occupy nurse’s time and effort but are not countable or recognized by the legislation (Buppert, 2005). Restriction on hospitals billing Medicare if reimbursements have been received under cost reports, further affect APNs as the amount received under cost reports is already fixed and limited as compared to hospital expenses. Another issue discovered is a rather vague role of current procedural terminology (CPT). These codes are expected to provide uniform language across national medical practitioners however there are several services that are not recognized under CPT and thus cannot be reimbursed by third parties i.e. insurers (Reimbursement Task Force, 2011). Another dogma affecting nurse’s ability to bill the righteous amount is their unawareness about the roles that they are playing and their stature in law. Studies indicated that where clinical nurse specialists are providing services as complex as physicians, they are perceived to be offering less-complexity services due to which appropriate CPT codes can be assigned to their services. Resultant is either getting lesser payments or sharing it with other physicians under whose code the service has been charged (Frakes & Evans, 2006). Another complication is the scattered nature of law when it comes to reimbursing APNs along with commercial payers following a complex payment mechanism. Employers and insurers have different organizational policies regarding reimbursing clinical nurses. Application of different rates dependent on the level services and acquiring information about these policies is a time-taking and complex procedure that hospitals have to undergo. Avoiding this hassle affects the amounts reimbursed to the nurses in Ohio (Buppert, 2005). According to Ohio Association of Advanced Practice nurses (2013), there is an increasing trend in Ohio witnessed when it comes to recognizing APNs as registered practitioners. Legitimacy of clinical nurses’ stature by private insurers gives them a chance to charge for reimbursements. However there are few insurers who do not consider services provided by advanced nurses as credential ones and enroll some of their services of physician’s panel. For this purpose, OAAPN is focusing on credential procedure of Ohio Advanced Practice Nurses so that requirements of private and commercial insurers can be met. Careful analysis reveals that Medicaid is a major source of reimbursement for APNs as Medicare covers only elderly and disabled whereas Medicaid provides coverage to all the low income segments. However, income eligibility criteria are defined in terms of age and physical health. Where clinical nurses are compensated mainly for providing services to elderly patients under Medicaid, it is important that they have their own APN provider number. Failure to have such enrollment would lead to non-receiving of revenues earned by them. It is the responsibility of registered nurse to ensure that are visible to state law and their employers through these ID numbers, in state of Ohio. Considering the current demography of United States, it can be seen that the population is ageing at a steady rate. In the lights of these facts the role of APRNs becomes more important as providing high quality care and care coordination for patients with acute conditions is one of the core functions of APNs. Where current law emphasize on having collaboration with physicians for registering Medicare benefits, APNs are the ones specializing in homecare services. Restricting APNs from certifying home health services and allowing patients to have extended care after hospitalization, increases burdens on general physicians. Although, major ground work is done by APRNs in case of complex medical conditions but reimbursement is provided to physicians only. One of the major issues faced by CNSs in Ohio is their invisibility in APN practices. The measures intended to identify the quality of services provided by CNSs is inaccurate which affects their reimbursement in turn. For instance, Medicare policy allows physicians to file for billing of services of APNs on “incident-to” basis. Such measures make APNs invisible as compared to physicians although reimbursement takes place at the same rate as physicians. However, direct filing makes them eligible of 85 percent reimbursement only as a result of which they prefer to work under physicians’ umbrella. Furthermore, lack of recognition of APNs in National Ambulatory Medical Care Survey also gives a rather biased picture of current healthcare landscape and role of APNs in them. Where these national surveys act as the guidelines for policy makers, invisibility of APNs in them leads to lack of recognition in national budget and related reimbursement policies (O’Grady, n.d.). Another major problem faced by APRNs in terms of Medicare is their submission of claims and issues in faced in their practice. Where most of the states including Ohio require collaboration with physicians for filing claims, APRNs encounter problems due to ambiguous definition of collaborative agreement in federal laws. As a result, states are given liberty to share their own definition of collaborative agreement. Presence of Medicare carriers further stretches the process of filing claims as their interpretation of collaborative agreement varies greatly. As Baradell and Hanrahan (2010) stated, “HCFA states specifically that, “Nurse practitioners and clinical nurse specialists are authorized by the Medicare program to bill for services that would otherwise be furnished by a physician. It is appropriate for the Medicare program to pay these non-physician practitioners who have the specific training mentioned for psychotherapy services that are determined to be medically reasonable and necessary”. This part of HCFA guidelines contradicts with Ohio’s legislation that make it mandatory for CNSs to collaborate with physicians’ that make their role rather invisible in the overall practice. Legal Status of APNs in Ohio According to amendments in the law of state of Ohio in 2012, APNs have complete legal authority to practice and these practices are duly regulated. However, this practice is not independent and can be performed in the form of collaboration between a physicians and Clinical Nurse Specialists (CNSs). Furthermore this practice can also be regulated through standard care arrangement. Where physicians are given a supervisory role when it comes to Clinical Registered Nurses, no such restriction is imposed on CNPs, CRNAs, CNMs, and CNSs. For patients’ admission, Clinical Nurse Specialists do not have any legal authority however; hospitals policies allow APNs to perform such important duties. As far as the legal categorization of reimbursement is concerned, CNSs are allowed to be compensated under worker’s compensation. Here, the flaws in hospital policies and shared reimbursements with physicians reduce the amount of revenues earned by CNSs. Furthermore, Ohio law recognizes CNSs having certification in gerontology, medical-surgical, and oncology. Those certified in family, adult and acute care are registered under different cadres of APNSs and are provided with different rates of reimbursements. Ohio law fails to stress on getting CNSs reimbursed by insurers unless they have policies saying otherwise and only recognizes mandatory reimbursements for midwives. Many commercial payers recognize the status of registered nurses, APNs and CNSs on the basis of their prescriptive authority. It can be seen that the prescriptive authority given to APNs including CNSs is under rigorous scrutiny. A prescription needs collaboration with the physician and nurses have to undergo a strict approval process for acquiring this authority. Due to tedious nature of this process, many registered nurses prefer not to apply for prescriptive authority and thus waive their right to reimbursement by themselves. Following the formulary devised by suitable bodies like e Interdisciplinary Committee on Prescriptive Governance is important otherwise. Such rigorous processing forces the nurses to perform risk aversion and not to apply for prescriptive authority due to which they are perceived as non-credential practitioners by various insurers (Phillips, 2012). Conclusion & Recommendations Critical analysis of the literature available on the subject matter indicated that there is a substantial opportunity for APNs especially Clinical Nurse Specialists to reimburse more amounts in return of their services. There is a significant room for legal authorities and US government to recognize the role of CNSs in healthcare and through acknowledging their role, necessary authority should be provided to them. Barriers like “incident to” that underestimate the role of nurse specialists in healthcare should be abolished by enhancing the criteria for credentials. Furthermore, a nation-wide regime should be introduced that can affect the policies of commercial payers. Where measures of government and state of Ohio allow CNSs to recover 85 percent of physician fee for the independently filed claims, many insurers fail to recognize them as a service provider that should be compensated for their services. Here, bodies like Ohio Association of Advanced Practice Nurses, are required to ensure that a massive campaign is introduced that could affect the policies of commercial payers. Furthermore, the scope of defined services needs to be increased. There are instances when nurses are offering services that are not recognized as billable one, resultant is lower compensation. Hospitals are also playing major role in aggravating issues faced by CNSs in terms of reimbursement. It can be seen that most of the hospitals do not pursuade commercial payers and insurers to consider CNSs as different category of payment. Limited resources paid to hospitals in terms of Medicare and Medicaid has enforced hospitals to hire nurses on contract basis instead of permanent employment. These nurses are often outsourced as a result of which they are not considered employees and eligible for benefits offered to hospital staff. In order to increase the revenues earned by CNSs in Ohio, it is important that nurses are made aware of their authorities and how law facilitates them. In addition to that, CNSs should embrace their evolving role. According to Buppert (2005), hospitals should facilitate CNSs when they cannot be paid in their individual capacity and should charge third party payers for physicians’ services. Furthermore, performance evaluation should be performed. Where a Clinical Registered Nurse is performing physician service, it should be made liability of the employer to evaluate and record this situation for billing purposes. Also, it should be ensured that a role of CNS in a joint practice with other physicians should be recorded well so that it could be billed to Medicare. Resultant can be unnecessary payments to physicians on the expense of APNs. Another significant role can be played by institutions developing APNs. It is important that APNs are aware of the current healthcare systems and jobs they are paid for. Training them for therapeutic and diagnostic procedures can help them receive more revenues. Thorough knowledge of CPT codes is also important. APNs especially CNS should know the codes for services they are providing and their billing amount. Knowledge of State law is of mandatory value. State of Ohio allows CNSs to perform several procedures under legislative authority if the credentials criteria are met. CNSs need to know if they are aware of their authority while performing certain procedures. Regulation of ANPs practice in Ohio is highly regulated by the State. Therefore, it is important that nurse specialists are aware of the financial details attached to their jobs. References Baradell, J. & Hanrahan, N. 2000. CPT Coding and Medicare Reimbursement Issues. Clinical Nurse Specialist, 14(6), pp. 299-3030. Buppert, C. (2005). Capturing Reimbursement for APN Services in Acute and Critical Care: Legal and Business Considerations, Retrieved from http://www.aacn.org/WD/CETests/Media/CI1612.pdf Delamaire, M. and G. Lafortune (2010), “Nurses in Advanced Roles: A Description and Evaluation of Experiences in 12 Developed Countries”, OECD Health Working Papers, 54, OECD Publishing. http://dx.doi.org/10.1787/5kmbrcfms5g7-en O’ Grady, E.T. (n.d). Advanced Practice Registered Nurses: The Impact on Patient Safety and Quality, Retrieved from http://www.ahrq.gov/qual/nurseshdbk/docs/OGradyE_APRN.pdf Ohio Association of Advanced Practice Nurses-OOAPN. (2011). Reimbursement, Retrieved from http://www.oaapn.org/index.php/reimbursement Phillips, S.J. (2012). APRN consensus model implementation and planning, The Nurse Practitioner, 37(1), pp.22-45. Reimbursement Task Force-WOCN. (2011). Reimbursement of Advanced Practice Registered Nurse Services: A Fact Sheet, Journal of Wound, Ostomy and Continence Nursing, 39(2S), pp. 7-16. Read More