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Medicare reimbursement for advanced practice nurses: In the front door!
Innovations at Emory University Hospital in Atlanta spanned a wide range of patient care improvements, including educating patients about their medicines; launching one of the first coronary care units with clinical specialists; the invention, with colleagues, of the individually packaged alcohol wipe; and the explication of the principle, in the 1960s, that "every patient admitted will have an RN responsible for their care." She modeled the role of administrator as problem solver, coach, and facilitator. After 23 years in nursing administration at Emory and Grady, Mary Woody became Founding Dean at Auburn University's School of Nursing in Alabama.
Anne Zimmerman Anne Zimmerman, a graduate of St. John's Hospital in Helena, Montana, was a pioneer in the movement to improve nurses' economic status and nurses' control of practice. In 1980 she received the Shirley Titus Award from the American Nurses Association (ANA) in recognition of her contributions as director of the Economic and General Welfare Program of the A N A ( 1951-52) and as member and chair of the Committee, and later the A N A Commission, on Economic & General Welfare. She continues to be one of the foremost authorities in this area.
1997 Living Legends Doris Schwartz, Anne Zimmerman, and Mabel Wandelt.
iii!~i~~
2 1997 Living Legends Mary Woody, Mary Kelly Mullane, and Jo Eleanor Elliott. Anne Zimmerman has been a nationally recognized leader for decades, demonstrating exceptional leadership. She served with distinction as executive administrator of the Illinois Nurses Association for 27 years, Assistant and Associate Director at the California Nurses Association, the executive secretary of the Montana Nurses' Association, president of the A N A (1976-78), member and
chair of the Board of Directors of the American Journal of Nursing Co., and member and vice chair of the Commission on Graduates of Foreign Nursing Schools. Her continuing influence on professional nurses is demonstrated by the e s t a b l i s h m e n t of the A m e r i c a n Nurses Foundation Research Endowment Fund in her honor in 1994. •
Op-Ed Medicare R e i m b u r s e m e n t f o r A d v a n c e d Practice Nurses: In t h e Front Door!
Eileen M. Sullivan-Marx, PhD, RN, FAAN January l, /998, may mark a turning point for advanced practice nursing. This OpEd uses the metaphor of the open door. What are the issues once we are inside? -Lorraine Tulman, DNSc, FAAN Op-Ed Editor
Ringing in this New Year is especially exciting for nursing! As of January 1, 1998, nurse practitioners (NPs) and clinical nurse specialists (CNSs) are able to bill Medicare and receive reimbursement for their services in all settings. The Primary Care Health
40 AAN News
Practitioner Incentive Act, part of the Balanced Budget Act of 1997, which was passed with strong bipartisan support and signed by President Clinton on August 5, 1997, represents more than 25 years of effort by nurses to break into mainstream health care payment. Before this new law was enacted, Medicare reimbursement for NPs was piecemeal and cumbersome, and payment for CNSs was nonexistent. Advanced practice nurses (APNs) were relegated to seeking payment through "back door" strategies, such as linking services to physician services. With di-
rect Medicare reimbursement, society has "opened the front door," paying APNs directly for care rendered. As the excitement subsides, however, the question arises, '~xlowwhat?" In my view, five areas of opportunity and challenge are immediately evident as a result of this legislation: (1) access, (2) visibility, (3) recognition, (4) business, and (5) policy.
Access A key impetus forging passage of this legislation was to increase access of primary
VOLUME 46 ° NUMBER 1
NURSINGOUTLOOK
care services for the Medicare beneficiaries who are the most underserved, such as persons who are homebound, elderly, urban-dwelling, female, and of minority status. Direct reimbursement for NPs and CNSs will expand opportunities for APNs to provide primary and specialty services in homes and other community settings, such as nurse-managed centers, fulfilling goals of Nursing's Agendafor Health Care Reformfor community-based care. In addition, Medicare beneficiaries in all settings will now benefit from care provided by NPs and CNSs. Innovative nursing practice models have demonstrated improved outcomes, such as reducing rehospitalization for patients with cardiac conditions and promoting individualized, restraint-free care in nursing homes. We must use the opportunity of direct Medicare reimbursement to make the transition from demonstration models of practice to mainstream practices using APNs for health care.
Visibility Although 100,000 advanced practice nurses in the United States provide an array of services to Medicare beneficiaries and others, advanced nursing practice has not been widely included in private or public financial databases. Medicare Part A payments to hospitals, skilled nursing facilities, home health agencies, and hospice programs cover nursing services but do not account for specific nursing interventions provided. Medicare Part B covers services of physicians and other providers, including APNs, on a fee-for-service basis in all settings using the Current Procedural Terminology (CPT) coding system. With direct billing, APNs will obtain provider identification numbers and bill for services covered by Medicare Part B. Provider numbers increase nursing visibility in two ways: (1) APNs will be included as providers in the annual Medicare Fee Schedule, and (2) as providers, APNs will have greater influence in coding and valuation systems used by the Health Care Financing Administration to identify and establish payment for services provided by APNs to Medicare beneficiaries. The Medicare Fee Schedule lists annual costs of all services paid by Medicare by type of pro-
NURSING OUTLOOK
vider. Including NPs and CNSs in this database creates an opportunity to link services provided by APNs with cost data. Before the new legislation was enacted, NPs billed "incident to" physician services under a physician provider number and hence were absent in the Medicare Fee Schedule except when billing in rural areas or in nursing facilities. Since 1993, APNs have participated, through the American Nurses Association, in development of CPT codes and relative work values as members of the American Medical Association's CPT and Relative Value Update Health Care Professional Advisory Committees. As directly reimbursed providers of Medicare services, APNs will have further opportunity to include specific nursing services in the CPT system and to account for the work value of services provided.
Recognition Payment is society's overt recognition of a professional group's authority to practice. The struggle to achieve direct reimbursement has been fraught with issues related to authority of nurses, including scope of practice, prescriptive authority, and educational preparation. In recent years both the public and private sector has extended greater recognition of APNs. The Institute of Medicine included NPs as primary care providers and, in the private sector, some managed care organizations have established contracts directly with APNs. By rendering direct reimbursement to APNs in the Medicare program, a program which represents one third of U.S. health care expenditures, society has taken a major step to legitimize the significant contributions that nursing makes to health care in the United States. We will need to be vigilant regarding the responsibilities placed on us by this recognition, not the least of which is to provide services to underserved Medicare beneficiaries in urban and rural environments.
livery systems and managed care organizations will be attracted to the contributions that APNs make to quality, access, and cost now that Medicare reimbursement is possible. Nurses, in turn, must develop and utilize business skills to take advantage of growing opportunities and overcome threats to their practice. As Medicare providers, APNs will be able to track revenues that they generate, whether they are employees in private practices or owners of nurse-managed businesses. Proficient business skills will enhance negotiation with managed care in assuming risk contracting or establishing salaries based on fee schedules.
Po~cy As identified Medicare providers, nurses can exert leadership regarding policies that have emerged in the Balanced Budget Act (BBA) of 1997, which represents the greatest adjustment to Medicare since its inception in 1965. This Act sets cost-cutting measures for Medicare, including reduced payment to home health care agencies, while it expands payment for specific health screening and education services. As Medicare gradually embraces managed care, nursing must have a strong voice in policy development at both federal and state levels. We need to use our new status as identified Medicare providers to position nursing in policy arenas that influence access, cost, and quality of services. Provision of health services to children and access to comprehensive mental health services must be a top priority for the nursing profession. For a long time the door to Medicare r e i m b u r s e m e n t was closed to APNs. Through incremental legislation during the past 10 years, we received reimbursement by knocking at Medicare's back door. Now, with direct reimbursement, the front door is open and we are walking in! Let's take advantage of every opportunity this affords nurses and our patients! []
Business Reimbursing APNs in all settings removes a major barrier that had previously limited opportunities for contracting with managed care organizations or setting up entrepreneurial enterprises. Integrated de-
JANUARY/FEBRUARY 1998
Eileen M. Sullivan-Marx is an Assistant Professor of Nursing and Director of the Primary Care-Adult Nurse Practitioner Program at the University of Pennsylvania School of Nursing, Philadelphia.
AAN News
41
Anne Zimmerman Anne Zimmerman, a graduate of St. John's Hospital in Helena, Montana, was a pioneer in the movement to improve nurses' economic status and nurses' control of practice. In 1980 she received the Shirley Titus Award from the American Nurses Association (ANA) in recognition of her contributions as director of the Economic and General Welfare Program of the A N A ( 1951-52) and as member and chair of the Committee, and later the A N A Commission, on Economic & General Welfare. She continues to be one of the foremost authorities in this area.
1997 Living Legends Doris Schwartz, Anne Zimmerman, and Mabel Wandelt.
iii!~i~~
2 1997 Living Legends Mary Woody, Mary Kelly Mullane, and Jo Eleanor Elliott. Anne Zimmerman has been a nationally recognized leader for decades, demonstrating exceptional leadership. She served with distinction as executive administrator of the Illinois Nurses Association for 27 years, Assistant and Associate Director at the California Nurses Association, the executive secretary of the Montana Nurses' Association, president of the A N A (1976-78), member and
chair of the Board of Directors of the American Journal of Nursing Co., and member and vice chair of the Commission on Graduates of Foreign Nursing Schools. Her continuing influence on professional nurses is demonstrated by the e s t a b l i s h m e n t of the A m e r i c a n Nurses Foundation Research Endowment Fund in her honor in 1994. •
Op-Ed Medicare R e i m b u r s e m e n t f o r A d v a n c e d Practice Nurses: In t h e Front Door!
Eileen M. Sullivan-Marx, PhD, RN, FAAN January l, /998, may mark a turning point for advanced practice nursing. This OpEd uses the metaphor of the open door. What are the issues once we are inside? -Lorraine Tulman, DNSc, FAAN Op-Ed Editor
Ringing in this New Year is especially exciting for nursing! As of January 1, 1998, nurse practitioners (NPs) and clinical nurse specialists (CNSs) are able to bill Medicare and receive reimbursement for their services in all settings. The Primary Care Health
40 AAN News
Practitioner Incentive Act, part of the Balanced Budget Act of 1997, which was passed with strong bipartisan support and signed by President Clinton on August 5, 1997, represents more than 25 years of effort by nurses to break into mainstream health care payment. Before this new law was enacted, Medicare reimbursement for NPs was piecemeal and cumbersome, and payment for CNSs was nonexistent. Advanced practice nurses (APNs) were relegated to seeking payment through "back door" strategies, such as linking services to physician services. With di-
rect Medicare reimbursement, society has "opened the front door," paying APNs directly for care rendered. As the excitement subsides, however, the question arises, '~xlowwhat?" In my view, five areas of opportunity and challenge are immediately evident as a result of this legislation: (1) access, (2) visibility, (3) recognition, (4) business, and (5) policy.
Access A key impetus forging passage of this legislation was to increase access of primary
VOLUME 46 ° NUMBER 1
NURSINGOUTLOOK
care services for the Medicare beneficiaries who are the most underserved, such as persons who are homebound, elderly, urban-dwelling, female, and of minority status. Direct reimbursement for NPs and CNSs will expand opportunities for APNs to provide primary and specialty services in homes and other community settings, such as nurse-managed centers, fulfilling goals of Nursing's Agendafor Health Care Reformfor community-based care. In addition, Medicare beneficiaries in all settings will now benefit from care provided by NPs and CNSs. Innovative nursing practice models have demonstrated improved outcomes, such as reducing rehospitalization for patients with cardiac conditions and promoting individualized, restraint-free care in nursing homes. We must use the opportunity of direct Medicare reimbursement to make the transition from demonstration models of practice to mainstream practices using APNs for health care.
Visibility Although 100,000 advanced practice nurses in the United States provide an array of services to Medicare beneficiaries and others, advanced nursing practice has not been widely included in private or public financial databases. Medicare Part A payments to hospitals, skilled nursing facilities, home health agencies, and hospice programs cover nursing services but do not account for specific nursing interventions provided. Medicare Part B covers services of physicians and other providers, including APNs, on a fee-for-service basis in all settings using the Current Procedural Terminology (CPT) coding system. With direct billing, APNs will obtain provider identification numbers and bill for services covered by Medicare Part B. Provider numbers increase nursing visibility in two ways: (1) APNs will be included as providers in the annual Medicare Fee Schedule, and (2) as providers, APNs will have greater influence in coding and valuation systems used by the Health Care Financing Administration to identify and establish payment for services provided by APNs to Medicare beneficiaries. The Medicare Fee Schedule lists annual costs of all services paid by Medicare by type of pro-
NURSING OUTLOOK
vider. Including NPs and CNSs in this database creates an opportunity to link services provided by APNs with cost data. Before the new legislation was enacted, NPs billed "incident to" physician services under a physician provider number and hence were absent in the Medicare Fee Schedule except when billing in rural areas or in nursing facilities. Since 1993, APNs have participated, through the American Nurses Association, in development of CPT codes and relative work values as members of the American Medical Association's CPT and Relative Value Update Health Care Professional Advisory Committees. As directly reimbursed providers of Medicare services, APNs will have further opportunity to include specific nursing services in the CPT system and to account for the work value of services provided.
Recognition Payment is society's overt recognition of a professional group's authority to practice. The struggle to achieve direct reimbursement has been fraught with issues related to authority of nurses, including scope of practice, prescriptive authority, and educational preparation. In recent years both the public and private sector has extended greater recognition of APNs. The Institute of Medicine included NPs as primary care providers and, in the private sector, some managed care organizations have established contracts directly with APNs. By rendering direct reimbursement to APNs in the Medicare program, a program which represents one third of U.S. health care expenditures, society has taken a major step to legitimize the significant contributions that nursing makes to health care in the United States. We will need to be vigilant regarding the responsibilities placed on us by this recognition, not the least of which is to provide services to underserved Medicare beneficiaries in urban and rural environments.
livery systems and managed care organizations will be attracted to the contributions that APNs make to quality, access, and cost now that Medicare reimbursement is possible. Nurses, in turn, must develop and utilize business skills to take advantage of growing opportunities and overcome threats to their practice. As Medicare providers, APNs will be able to track revenues that they generate, whether they are employees in private practices or owners of nurse-managed businesses. Proficient business skills will enhance negotiation with managed care in assuming risk contracting or establishing salaries based on fee schedules.
Po~cy As identified Medicare providers, nurses can exert leadership regarding policies that have emerged in the Balanced Budget Act (BBA) of 1997, which represents the greatest adjustment to Medicare since its inception in 1965. This Act sets cost-cutting measures for Medicare, including reduced payment to home health care agencies, while it expands payment for specific health screening and education services. As Medicare gradually embraces managed care, nursing must have a strong voice in policy development at both federal and state levels. We need to use our new status as identified Medicare providers to position nursing in policy arenas that influence access, cost, and quality of services. Provision of health services to children and access to comprehensive mental health services must be a top priority for the nursing profession. For a long time the door to Medicare r e i m b u r s e m e n t was closed to APNs. Through incremental legislation during the past 10 years, we received reimbursement by knocking at Medicare's back door. Now, with direct reimbursement, the front door is open and we are walking in! Let's take advantage of every opportunity this affords nurses and our patients! []
Business Reimbursing APNs in all settings removes a major barrier that had previously limited opportunities for contracting with managed care organizations or setting up entrepreneurial enterprises. Integrated de-
JANUARY/FEBRUARY 1998
Eileen M. Sullivan-Marx is an Assistant Professor of Nursing and Director of the Primary Care-Adult Nurse Practitioner Program at the University of Pennsylvania School of Nursing, Philadelphia.
AAN News
41