Essay Sample on Medical Reimbursement: Congress Sanctioning Direct Reimbursement of NPs

Introduction

Nagelkerk (2005) argues that billing for health care is a contemporary process that requires clients to make out-of-pocket payment in cash or through barter for health services rendered. Once the hospitals and physicians receive the payments after providing services to Medicare recipients then that is termed as Medical reimbursement. In 1997, Congress sanctioned direct reimbursement of Nurse Practitioners regardless of the geographic practice (Nagelkerk, 2005). The rate of NP reimbursement was set at 85% of actual care (Nagelkerk, 2005). The reimbursement stretches also to NPS working for medical practices, and satisfy the "incident to" requirements. NPS should also bill through their provider number.

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Buppert (2002) postulates that a medical reimbursement occurs once an NP and a physician work collaboratively to offer health services, the services are normally billed under the physician's beneficiary number, to access the full reimbursement under the Medicare provision for "incident to billing." Organizations can use "incident-to-billing" after strictly following certain rules laid forth by Medicare. The services being rendered by the physicians should be very important, however incidental part of the physician's professional service. The services normally offered without a fee or included in the doctor's bill. The most important thing is the physicians must perform "the preliminary service, progressive health services of an incidence which echoes his or her active participation in the management of the treatment course." "Incident to" billing may be illegal in the case where a physician hires an NP to offer health service in one of the hospital's satellite clinics, and the doctor is never present that requirements in this care would not have been met.

Buppert (2002) confers several instances where the hospital can apply the "incident to" billing. An instance of appropriate use would occur when a doctor assesses a new patient to a practice, diagnoses hypertension, and starts the treatment procedure. The NP who is hired by the physician attends to the patient during the regular follow-up visits, but the doctor also attends to the patients periodically then "incident to" billing would be effective in this case.

Medicare billing consists of two parts namely Part A and Part B. Part A consists of Hospital Insurance, and Part B comprises of Additional Medical Insurance (Buppert, 2002). In Part A, reimbursement depends on the beneficiaries' fee as deliberated with the fiscal intermediary, (FI). Reimbursement involves services rendered by home health agencies, rural health hospitals, skilled nursing facilities and nursing homes (Buppert, 2002). For inpatients, reimbursements are done at a specific rate per discharge. Medicare Part B is centered on an established "fee-for-service" sent to the Medicare agencies. These services comprise of laboratory tests, injectables, and durable medical equipment. NPs are directly paid for their service at 85% of the doctor's fee schedule rate for the services he or she renders to beneficiaries of Medicare (Buppert, 2002). Exstrom (2001), argues that many health-related agencies and state boards have an important role to play in ensuring patients get quality health care via the issuance of certificates, to nurses that are skilled.

There are several requirements that Medicare expects an organization to fully comply to. Medicare expects the health organization to have the ability to render enhanced clinical, and non-clinical quality of care and services to Medicare beneficiaries (Buppert, 2017). The organization should also be able to generate an accurate monthly evaluation of worker and contractor behavior relating to fraud or abuse. Buppert (2002) highlight some of the specific requirements of Medicare on managed care organizations (MCO) for NP services. Medicare billing will only occur for those providers admitted to the plan's benefactor panels. Nagelkerk (2005), highlights the three most common Medicare policies and rules on MCO for NP services. First, admitting NPs to the benefactor's board; refusing to 'empanel' NPs, but permitting NPs to offer service on a physician's panel. Finally, refusing to impanel NPs and restricting MCO patients from receiving care offered by an NP in lieu of a doctor.

CMS defines medical fraud as intentionally asking for, accepting, offering, and/or paying salaries to entice or reward referrals for services paid by Medicare (Blair & Jansen, 2015). In order to address medical fraud health care organizations, hire coding experts and consultants to review audits and train staffs on how they can detect an instance of fraud. Further, most organization design a superbill for processing claim that involves all the coded information in one section (Blair & Jansen, 2015). The areas where the fraud investigation is done include the charges remitted for complex and specialized procedures, vaccines, E&M codes. APRNs are supposed to give information on regular occasions with billing, coding, and audit staff (Blair & Jansen, 2015). They are also involved in regular revision, and assessment of the superbill to ensure curb future medical fraud.

Health care organization are also trying to ensure there are adequate documentation and coding results to curb the loss of revenue as a result of fraud (Blair & Jansen, 2015). Accurate documentation enhances the quality and precision of the audit report. APRN has been trained on coding requirements to hasten the detection of any Fraudulent act if and when it occurs (Blair & Jansen, 2015). They are also improving on their efforts to track outcomes of health care, and further enforcing penalties if discrepancies are detected. Fitzpatrick (2003) argues that in order to curb fraud organization should have strict ways of issuing out licenses to NPs and they should also revoke any licensure of an NP caught with any fraudulent act while in the line of duty. Providence of the license is not only based on entry-level competence by NP but also fingerprints should be taken from Nurses to assess the criminal or fraudulent report (Fitzpatrick, 2003). The stark law bars beneficiaries' from making referrals of certain health care service billed by the federal health programs to an organization in which the provider has an investment.

References

Blair, K. A., & Jansen, M. P. (Eds.). (2015). Advanced practice nursing: Core concepts for professional role development. Springer Publishing Company. Retrieved from: https://books.google.co.ke/books?hl=en&lr=&id=y2EBCAAAQBAJ&oi=fnd&pg=PP1&dq=Nursing+practice+by+Blair+and+Jansen&ots=Kn61evG3G7&sig=NAha6Y63abQwi6Jd4morkPpsjg&redir_esc=y#v=onepage&q=Nursing%20practice%20by%20Blair%20and%20Jansen&f=false

Buppert, C. (2002). Billing for nurse practitioner services: Guidelines for NPs, physicians, employers, and insurers. Medscape Nurses, 4(1). Retrieved from: https://www.mc.vanderbilt.edu/documents/CAPNAH/files/Mentoring/Section%204/Billing%20for%20Nurse%20Practitioner%20svcs_%20Guidelines%20for%20NPs%20Phys%20Employers%20and%20Insurers.pdf

Buppert, C. (2017). Nurse practitioner's business practice and legal guide. Jones & Bartlett Learning.

Exstrom, S. M. (2001). The state board of nursing and its role in continued competency. The Journal of Continuing Education in Nursing, 32(3), 118-125. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/11868703

Fitzpatrick, M. A. (2003). Certified practice: We owe it to our patients and ourselves. Retrieved from: https://www.nursingcenter.com/pdfjournal?AID=405532&an=00006247-200303000-00001&Journal_ID=54013&Issue_ID=405531

Nagelkerk, J. (2005). Starting Your Practice: A Survival Guide for Nurse Practitioners. Elsevier Health Sciences. Retrieved from: https://books.google.co.ke/books?hl=en&lr=&id=yPGZPTSmnAQC&oi=fnd&pg=PR3&dq=Starting+your+practice:+A+survival+Guide+for+Nurse+Practitioners+by+Jean+Nagelkerk&ots=8G5wZd2lS4&sig=dCLcQVmNV3QTLG8DCdCCxlhHOBs&redir_esc=y#v=onepage&q=Starting%20your%20practice%3A%20A%20survival%20Guide%20for%20Nurse%20Practitioners%20by%20Jean%20Nagelkerk&f=false