Insurance Company Refusal

Our thanks to Linda Carlson, MS, CPNP, and Colleen Kochman, MSN, CPNP for providing the answer to this question.

Question: What can I do when an insurance company refuses to pay for care provided by a PNP?

Answer: Although it is slowly changing, the standard and generally accepted practice for billing for NP provided services has been to bill under the collaborating physician's group or facility provider number. This is considered legal unless an insurer has a specific stated policy stating otherwise. It is important to first know what, if any, state laws exist regarding NP reimbursement. If there are no statutes mandating NP reimbursement, each individual insurer has the right to set their own policies. A call to the specific insurer to request their policies in writing can be enlightening. Many insurers do not have any policies in place and are not prepared to deal with this issue until they are pressured to do so by state law, insurance commissioners, NP organizations or consumers. If not policy exists, it will be harder for them to refuse payment for billing under a group provider #. Sometimes it depends on who is processing the claim, a resubmitted claim under a collaborating physician or group # may be accepted by another processor. It may also be helpful to ask for help from your billing department, who may know how to get the claim approved.