By Carolyn Buppert
Carolyn Buppert, JD, NP is a health care attorney. Her legal clients include medical practices, institutions, non-profit organizations and individual clinicians throughout the United States. She is the author of eight books, and her column offers tips and advice on financial issues. Visit her website to learn more about her: www.buppert.com.
Nurse practitioners (NPs) sometimes ask how to get credentialed with commercial health plans and insurers. The answer is a two-part process. First, you should go to www.caqh.org and fill out the provider credentialing application. The Council for Affordable Quality Healthcare, or CAQH, is a centralized “universal” source of data that commercial payers generally use for credentialing. Then, contact the payer you wish to be able to bill, and ask how to set up a contract. The payer will go to CAQH for your credentialing information and make a decision about whether or not it wants to contract with you and, if so, the terms.
Most payers are now credentialing and reimbursing NPs, either directly, if the NP is selfemployed, or through the NP’s employer. Aetna recently changed its policy on reimbursement of NPs. For many years, Aetna did not credential NPs; on the other hand, if a physician employer who was credentialed by Aetna utilized NPs, the services provided by those NPs could be billed under the physician’s name, and the physician would receive 100% of the physician rate. However, it was difficult to obtain this policy in writing from Aetna. It was posted on the company website for a while about 5 years ago and then disappeared. In March 2010, Aetna posted the following notice in its newsletter:“Reimbursement change for mid-level practitioners–
Certified registered nurse anesthetists, registered nurse first assistants or behavioral health practitioners
Claims billed with an assistant surgery modifier
Covered DME, orthotics, prosthetics, supplies, drugs, laboratory, radiology services and immunizations billed by a mid-level practitioner
Medicare Private Fee-for-Service (non-network based)
Providers contracted through a third party or vendor
Also, we want to make sure the names of all your practices’ mid-level practitioners display in our directories.
* This policy will not apply in the states of Alaska, Kansas, Maine and Missouri.”
(Source available at www.aetna.com/provider/data/OLU_MA_MAR2010_fin.pdf)
In June 2010, Aetna posted the following statement in the company’s provider newsletter.
“In the March 2010 issue, we noted that beginning June 1, 2010 Aetna will pay midlevel practitioners at 85 percent* of the contracted rates for covered professional services. This is consistent with the Centers for Medicare & Medicaid Services payment policy. Under this policy, Aetna will allow payment at the full contracted rate for services that are provided in accordance with the Medicare definition of ‘incident to’ and are properly documented in the patient’s chart. *This policy does not apply in the states of Alaska, Kansas, Maine, Michigan and Missouri.”
(Source available at www.aetna.com/provider/data/OLU_MA_JUN2010_final.pdf)
The physician has provided the initial service, ie, a new patient visit or service for a new problem.
The physician is in the suite when the NP performs the service.
The physician remains involved in the care of the patient.
The physician employs or has a contract with the NP.
Care First Blue Cross
Care First Blue Cross made a policy change several years ago and published the following change in its newsletter.
“Nurse Practitioners Must Be Credentialed and Obtain Their Own Provider Numbers. All Certified Registered Nurse Practitioners must be individually credentialed, issued a unique provider and member number, and be identified on claims as the practitioner rendering service. Nurse Practitioners are re-credentialed every three years as are all participating practitioners. If your practice includes Nurse Practitioner(s) who are not credentialed with individual provider numbers, you must submit a completed credentialing application and billing authorization form for each.”
(Source available at www.carefirst.com/providers/BlueLink/attachments/BlueLink_200706.pdf)
Last year, Care First audited one practice and claimed that the practice must repay monies it paid for an NP’s services because the NP was not credentialed. Note that Blue Cross maintained for many years that it did not credential NPs; however, if a physician wanted to hire an NP and have that NP see patients, Blue Cross did not object to the physician billing for the NP’s services under the physician’s name. The practice countered that it had tried to credential the NP, and Care First eventually backed down on that demand for refund of monies paid.
The important message here is that each commercial indemnity insurer makes its own rules regarding who it will credential and the process of reimbursement. A practice, institution, or facility must query each insurer about its policies and respond according to that organization’s process. The American Academy of Physician Assistants provides state-by-state payer profiles (available at www.aapa.org/advocacy-and-practiceresources/reimbursement/payer-profiles/929-private-payer-profiles). Practices that employ NPs may use this resource as a starting point for developing a database of payers’ policies. Practice managers may find it useful to prepare grids that track the various insurers’ policies. The following is one example of such a grid.
When a payer does not specifically state that an NP’s services may be billed under a physician’s name or number, a practice is at some risk for a charge of improper billing if a payer later claims it wanted services billed under the name and provider number of the individual who actually performed the service. To be very sure that the payer does not contend at a later date that it wanted a practice to follow Medicare’s rules, the author recommends the following strategy.
1. Develop a policy regarding how the practice or facility will bill the NP’s services, and notify the payers of that policy. For example, the policy might state: “Physician services at [insert your practice or facility name here] may be provided by qualified nurse practitioners under the provisions of state law. Health plans or indemnity insurers who have specific requirements regarding the clinician under whose name such services are billed must state those requirements, in writing, to [insert your practice name here]’s billing manager. Lacking written direction from a payer, our billing manager will decide whether a nurse practitioner’s services are billed under the nurse practitioner’s name or under the name of a physician credentialed with the payer.”
2. Using certified mail, send the practice’s policy to the appropriate contact person at each commercial payer, with a cover letter that states:
“This is our practice’s policy. If your organization has specific requirements regarding billing of physician services provided by nurse practitioners, please respond to me in writing, specifying such requirements, within 15 days. If I do not receive specific written directions from your organization by [insert date], [insert your practice name here] will assume that this distinction is not important to your organization and will bill a nurse practitioner’s services under one of our physician’s names or under the nurse practitioner’s name, depending upon which clinician is on the payer’s panel.”
3. Track and file the payers’ responses and bill accordingly. If there is no response, follow the policy as you have stated it to the payer. Dissemination of such a policy to each payer should be sufficient to protect the practice from claims of inappropriate billing.