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Nurse Practitioners Should Get Reimbursement Parity

Author(s): Dave Gilmartin

Nurse practitioners should be reimbursed by Medicare at 100 percent, up from the current 85 percent, to bring them into parity with physicians, according to the authors of a paper published in the Online Journal of Issues in Nursing.

Authors Alycia Bischof, MSN, APRN, PNP-BC and Sherry A. Greenberg, PhD, RN, GNP-BC, FGSA, FAANP, FAAN argue that NPs provide the same quality of care as physicians and increasing the reimbursement would help fill the shortage of primary care physicians.

“The 85 percent rule was instituted at a time when the work environment looked very different. With an increase in full practice authority states, and nurse-managed healthcare centers and retail clinics, many NPs practice independently,” they wrote.

‘Incident to’ billing hurts NP reimbursement parity

One change the authors recommend is to Medicare’s policy of reimbursing 100 percent of the cost for “incident to” billing where an NP delivers the care, but the services are billed under the name of a physician, who is required to be part of the practice.

“What this means in practice is that many practice owners would rather see NPs bill ‘incident to’ than under their own provider number,” they wrote. “Why would anyone running a practice want to lose 15 percent of revenue for every patient that the NP sees?”

“Incident to” billing is also a detriment to NPs who own their own practice and so can only get 85 percent reimbursement.

Aside from providing a financial disincentive to NPs, the practice hides the true impact of nurse practitioners because “incident to” billing is submitted under the physician’s name.

“NPPs have a choice: bill under their own provider number and receive 85% reimbursement and accurately track NP-specific practice trends and payments or, satisfy the ‘incident to’ rules and receive 100% reimbursement,” they wrote. “This is important because, if billing under the physician’s provider number, the NPP’s name never appears in the billing records. Therefore, it is difficult for payers and the public to recognize the productivity of the NPP.

History of Nurse Practitioner (NP) Reimbursement from Centers for Medicare and Medicaid Services (CMS)
History of Nurse Practitioner (NP) Reimbursement from Centers for Medicare and Medicaid Services (CMS)

“Recognition of this productivity by both parties is crucial for NPPs to receive parity for equal services.”

Pandemic shows value of NPs

The last year has demonstrated the value of NPs as states granted them full practice authority to help with the pandemic.

“The Covid-19 pandemic demonstrated how removal of practice restrictions can increase the care NPs can deliver, while maintaining quality,” the authors wrote. “As the number of states allowing full practice authority for NPs grows, barriers to practice need removal.

“Nurse-managed health centers and retail clinics, run primarily by NPs, confirm the impact that NPs can have in delivery of high quality, cost effective care.”


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