MDC APRN Reimbursement Impact and Variability Discussion

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1. In the healthcare system, APRNs are essential because they offer patients high-quality treatment and services. However, depending on the payer, whether it’s Medicare, Medicaid, private insurers, or HMOs, the reimbursement policy for APRNs vary. Additionally, the pricing schedules for medical professionals and non-physician providers like APRNs could differ. State laws may also have an impact on APRNs’ ability to own their practices in Florida. Reimbursement mechanisms for APRNs depends on what insurance provider we are referring to. Medicare is a federal program that provides health insurance coverage primarily for people aged 65 and older, as well as some younger individuals with specific disabilities (Centers for Medicare & Medicaid Services, 2021). Medicare recognizes APRNs as eligible providers, and they are reimbursed for their services based on the Medicare Physician Fee Schedule, MPFS. This means that APRNs receive payment rates similar to physicians for services rendered to Medicare beneficiaries (Centers for Medicare & Medicaid Services, 2021).

Medicaid, on the other hand, is a joint federal and state program that provides health coverage for low-income individuals and families (Florida Department of Health, 2021). The reimbursement mechanism for APRNs under Medicaid can vary from state to state. In Florida, Medicaid recognizes APRNs as providers, and their services are reimbursed at a rate equivalent to that of physicians for certain covered services (Florida Department of Health, 2021).

Private insurers determine their reimbursement policies independently, and therefore, the reimbursement rates for APRNs can vary between different insurance companies in Florida. However, many private insurers recognize APRNs as primary care providers and reimburse them at rates comparable to physicians for specific services (American Association of Nurse Practitioners, 2021).

Lastly, HMOs are managed care organizations that provide healthcare services to members for a fixed annual fee. The reimbursement mechanisms for APRNs within HMOs can differ, depending on the specific HMO contract. In some cases, APRNs may be reimbursed at rates similar to physicians for specific services, while in others, they may be reimbursed at a different rate (Florida Office of Insurance Regulation, 2021).

Physicians and APRNs in Florida have historically had some differences in their pricing schedules. However, initiatives have been taken to close this gap and acknowledge the importance of APRNs as primary care providers. For instance, the Consolidated Appropriations Act of 2021 contained provisions allowing APRNs to deliver some Medicare-covered services and be paid at 85% of the physician fee schedule (American Association of Nurse Practitioners, 2021). This was a huge step towards reducing the disparities in fee schedules between physicians and APRNs (American Association of Nurse Practitioners, 2021). As of September 2021, Florida legislation mandates that in order to practice, APRNs must have a collaborative agreement with a doctor (American Association of Nurse Practitioners, 2021). This means that in order to offer specific medical services, APRNs needed a formal contract with a doctor and were unable to independently own their businesses (American Association of Nurse Practitioners, 2021). The scope of practice for the APRN and the amount of oversight needed from the collaborating physician are specified in the collaboration agreement (American Association of Nurse Practitioners, 2021).

2. According to American Nurses Association (ANA), the federal law requires fee-for-service Medicaid to cover services/practices provided by APRNs. APRN care is reimbursable only to the extent that the services are ones the practitioner is authorized to provide under the state law applies. (ANA, 2020) Therefore, decisions regarding nurse practitioner reimbursement can be made at the state level, which in turn vary by state. States reimburse nurse practitioners at anywhere from 75% to 100% of the physician rate for Medicaid.

Many studies have proven that APRNs provide cost-effective, high-quality care. In addition, APRNs are often willing to provide services in rural and inner-city areas where access to physicians is limited to, yet billing for nurse practitioner is a complex. (ANA, 2020) Many Medicare plans reimburse APRNs at a fraction (85%) of the physician fee schedule, that is, they get paid 80% of the 85% of the physician fee schedule rate for a healthcare service. For an example, if the physician fee schedule rate for a certain healthcare service was $100, Medicare would pay the physician $80 and charge the patient $20. If it is NP who provided the healthcare service, Medicare would pay the nurse practitioner 85% of $80 which would be $68, and patient would pay $17 to the nurse practitioner. (Buppert, 2020)

I currently live in California, and in 2020, Governor Gavin Newsom signed into law Assembly Bill 890, which allows expanding nurse practitioner practice authority where nurse practitioners can own their practices and no longer need to work under physicians’ supervision. This will help increasing access to healthcare and lowering healthcare cost.

3. What type of multidisciplinary practices have you seen in healthcare facilities? Is there anything you, as APRN, would do differently, and Why?