¶ … Reimbursement barriers and issues that hinder or prevent Advanced Practice Nurses (APNs): What are steps APNs must take to increase the likelihood for reimbursement?
'An ounce of prevention is worth a pound of cure.' In addition to the stresses and the difficulties experienced by nurses in treating patients, getting reimbursed as a nurse practitioner can be an additional challenge. Taking defensive mechanisms to ensure payment is essential for APNs when navigating the thorny path of the medical insurance bureaucracy.
Government insurance programs like Medicare and Medicaid usually have fairly standardized policies for reimbursement for physician services performed by nurse practitioners. However, different private health plans often vary considerably, and it is essential that the APN understands what type of plan she is dealing with before embarking upon treatment. Even when dealing with Medicare, the nurse must remember that Medicare reimbursement only occurs when there is a collaborative agreement with a physician and thus it is often better to get such an agreement in writing if at all possible (Buppert, 2006, How to avoid). Nurses cannot merely assume that because they are ordered to perform a procedure by a physician on staff it will automatically be reimbursed, nor can they even be certain that physicians on staff are compliant with all currently-existing laws.
Nurses must take steps to be proactive regarding the process of reimbursement. Susan Cooper calls this taking responsibility and ownership of the process rather than merely being passive (Cooper 2000). Nurses must be involved reading contracts, reviewing claim submissions requirements, appeals, covered services; and understanding reimbursement terminology such as capitation vs. fee for service considerations (Cooper 2000). APNs should be also familiar with documentation requirements to support proper CPT and ICD coding (Cooper 2000; Buppert, 2006, Top 10 must dos). When dealing with third party insurers such as Blue Cross, they must also ensure that they have been appropriately credentialed by the provider. Not only must the procedures be approved and the insurance of the patient must be current -- the laboratories where tests are performed must be approved by the provider as well (Buppert, 2006, How to avoid).
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