WCU Payment Disparities for APRNs vs Physicians Discussion

Jalil D Response 1

Medicare, Medicaid, private insurers, and HMOs are reimbursement mechanisms designed to make payments to APRNs for services rendered. Notably, most billing regulations for insurers follow the Medicare guidelines. Payments to APRNs are only made on an assignment basis that follows the Medicare-allowed amount. Consequently, APRNS are not allowed to collect or bill the beneficiary any amount apart from unmet copayments, coinsurance, and deductibles. However, payment is made to APRNs unbundled when inpatient and outpatient hospital services are billed directly. 

Differences exist between physicians and non-physician providers. For instance, while the reimbursement for non-physician providers tends to be based on direct diagnosis-related groups, provider services are made independently from the respective system. It is also important to note that payment for nursing services is equivalent to 85% of the doctor’s payment plan. The reimbursement of provider services is done independently from other services offered in healthcare facilities. On the one hand, payments for provider services are made through Part B of Medicare, which includes surgery, therapy, diagnosis, care plan oversight, consultations, and institutional and home visits. Billing done for inpatient services for physician services uses the Current Procedural Terminology (CPT) code system. On the other hand, non-physician services use the Evaluation and Management (E&M) service, which includes coordination of care, counseling, diagnosis, history taking, and examination.

Previously, APRNs were not allowed to have their practice in California. However, from the beginning of 2023, APRNs in California State could apply for licenses to operate their practice (Haney, 2023). The main reason for this authorization is that NPs are essential leaders in healthcare teams where standardized procedures are needed to ensure that they function within their area of practice to meet patients’ primary healthcare needs.

Rocio R Response 2

Reimbursement mechanisms for Advanced Practice Registered Nurses (APRNs) vary depending on the payer, whether it’s Medicare, Medicaid, private insurers, or Health Maintenance Organizations (HMOs). In the case of Medicare, it reimburses APRNs for services provided under certain conditions. For example, nurse practitioners, clinical nurse specialists, and certified nurse-midwives can be reimbursed for services they independently provided within their scope of practice and state laws (Harrison et al., 2023). However, certified registered nurse anesthetists typically receive reimbursement under physician supervision rules (Harrison et al., 2023). In addition, Medicaid reimbursement for APRNs also varies by state regulations and scope of practice laws. While some states allow APRNs full practice authority, enabling them to bill Medicaid directly for their services without physician oversight, other states require that APRNs collaborate with physicians to receive reimbursement (Harrison et al., 2023).

Private insurers typically follow Medicare guidelines but may have their reimbursement policies regarding APRN services. Many private insurers reimburse APRNs for services within their scope of practice, although the rates may vary (Leger & Vanhook, 2021). On the other hand, Health Maintenance Organizations (HMOs) often have reimbursement policies for APRNs that may reimburse APRNs depending on the specific HMO and its contract agreements with healthcare providers (Leger & Vanhook, 2021).

Regarding fee schedules, there are often differences between physicians and non-physician providers (NPPs) such as APRNs. 

According to Bischof & Greenberg (2021), Medicare generally pays APRNs at 80 percent of the lesser of the actual charge or 85 percent of physician payment under the Medicaid Physician Fee Schedule. Those reimbursement rates differ due to the scope of practice between physicians and NPs, billing rules and market dynamics, that include negotiations between healthcare providers, insurers, and government agencies (Razavi et al., 2021).

Finally, Advanced Practice Registered Nurses (APRNs) can own their practices in Florida in primary care, including family medicine, general pediatrics, and general internal medicine (APRN, 2024). Florida is one of the states that allows APRNs to practice independently without physician supervision under certain conditions. The ability of APRNs to own their practices in Florida is influenced by factors such as the scope of practice laws, state licensing requirements, and business regulations (APRN, 2024).