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Nurse Practitioner Reimbursement Gap Remains Among Public, Third-Party Health Insurance Payers

Nurse Practitioner Reimbursement Gap Remains Among Public, Third-Party Health Insurance Payers
Equal Reimbursement for Services Would Support Better Outcome Data

The National Association of Pediatric Nurse Practitioners (NAPNAP) recently revised its position statement on the status of reimbursement policies of public and third-party payers for health care services provided by nurse practitioners. The statement was published in the May/June issue of the Journal for Pediatric Health Care.

“Under current payment models, Medicare reimbursement, state Medicaid programs and third-party payers, nurse practitioners are reimbursed only about 85 percent of the rate paid to physicians for providing the exact same services,” said NAPNAP President Laura Searcy, MN, APRN, PPCNP-BC. “This biased, inequitable payment system sometimes leads to questionable provider billing. Even worse, nurse practitioner outcome data are almost always obscured because their services are hidden under the higher-paid physicians’ provider numbers so a private practice or hospital can collect the maximum payment.”

NAPNAP believes nurse practitioners must be reimbursed commensurate with physicians for the same services when delivered to the same type of patients. This payment inequity has existed since 1997 with the implementation of Balanced Budget Act and its overhaul of the Medicare payment system. Although nurse practitioners and other providers opposed the regulation, physicians were paid 100 percent for services while other providers had their payment levels arbitrarily reduced. Nurse practitioners are independently licensed providers of primary and acute care, have demonstrated the ability to provide high-quality health care, and incur the same overhead costs as physicians who provide care to patients.

The updated NAPNAP position statement calls for comprehensive documentation of nurse practitioner service delivery to support full reimbursement for and measurement of nurse practitioner contributions to care, patient outcomes data and development of team-based care models.

“The billing, coding, electronic medical records and culture of health care were substantially different in 1997,” said Searcy. “With the advent of big data, there are no realistic barriers that prevent the health care system from supporting reimbursement parity.”

“It’s imperative that we report discriminatory payment practices that are prohibited under the Affordable Care Act regulations,” urged Searcy. “Until we speak up to federal agencies and state insurance commissioners, nurse practitioners are going to be denied direct and equitable payment for the health care services we provide.”

Reimbursement inequity has a greater effect on women as the majority of nurse practitioners are female. In addition, payers are negatively affected by the inequity and should be able to pay a fair price regardless of provider.

NAPNAP advocates for continuing public and private research to demonstrate the cost effectiveness, competency, patient outcomes and quality measures of nurse practitioner practice.

To view the position statement, visit jpedhc.org.                            

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The National Association of Pediatric Nurse Practitioners (NAPNAP) is the nation’s only professional association for pediatric-focused advanced practice registered nurses (APRNs) dedicated to improving the quality of health care for infants, children, adolescents and young adults. Representing more than 8,500 healthcare practitioners with 17 special interest groups and 49 chapters, NAPNAP has been advocating for children’s health since 1973 and was the first APRN society in the U.S. Our mission is to empower pediatric-focused APRNs and their interprofessional partners to enhance child and family health through leadership, advocacy, professional practice, education and research. www.NAPNAP.org