Dr Stefanacci is the chief medical director for the managed markets agency of EVERSANA™. Dr Pakizegee is the clinical content lead for Government Policy Systems at the managed markets division of EVERSANA™.
EVERSANA™, Berkeley Heights, NJ
With a projection short fall of between 46,900 and 121,900 physicians in the health care workforce by 2032, who will fill the gap?1 One answer could be nurse practitioners (NPs). NPs are advanced practice registered nurses (APRNs) who are prepared through advanced graduate education and clinical training to provide a range of health services, including the diagnosis and management of common as well as complex medical conditions to people of all ages. They hold advanced degrees, either an MSN (Master of Science in Nursing) or DNP (Doctor of Nursing Practice), national certification in a patient population focus, and state APRN licensure. APRNs are helping to mitigate the effects of the national physician shortage by serving as primary care providers (PCPs).
In 2010, there were approximately 56,000 NPs practicing primary care in the United States, according to research commissioned by the Agency for Healthcare Research and Quality. This is 52% of the total number of NPs in the United States.2 The number of APRNs has more than doubled today, with the majority still involved in primary care. Part of this growth is the result of demand and an enticing salary. The average APRN salary in the United States is $105,953 as of January 31, 2019, but the range typically falls between $98,315 and $115,100. Salary ranges can vary widely depending on many important factors, including education, certifications, additional skills, and the number of years spent in your profession.3
Skilled nursing facilities (SNFs) can employ NPs to better serve their SNF residents and facility. Given the importance of increasing the level of services provided by SNFs to maintain inclusion in hospital preferred networks, employing NPs in SNFs can bring much value to care processes. SNF directors and administrators should understand the training and scope of services of NPs in order to best utilize them in their facilities.
NP Scope of Practice
The role of the NP can differ somewhat depending on the state in which the nurse is practicing. Certain states allow NPs to work independently, whereas others require them to work under either direct supervision or a collaborative agreement with a doctor.4 Their scope of services varies in three areas: practice authority, prescriptive authority, and NP authority when functioning as a PCP.
Practice authority can be defined as NPs’ ability to practice independently without physician oversight. This often requires having a relationship with a physician that outlines procedures the NP may perform and procedures for consulting with the physician. In some states, policy specifies whether an NP must complete a transition to practice period before practicing independently. In other states, NPs have full independent practice authority, meaning they practice independently with no physician oversight.
Prescriptive authority refers to an NP’s authority to prescribe medications. Some states require a relationship with a physician that outlines the NP’s prescribing abilities. Some states specify whether an NP must complete a transition to practice period before being able to prescribe independently. State law in some areas allows NPs to prescribe medications independently without physician oversight.
Finally, some states will explicitly identify an NP as a PCP, which may include primary care being defined as a population focus for an NP. Other states do not explicitly identify NPs and PCPs.
Billing NPs in SNFs
In SNFs, NPs bill under their own provider number. However, outside of SNFs, NPs have the ability to capture 100% of the physician fee schedule instead of 85% when they bill on their own. To capture 100%, NPs must bill “incident-to” a physician. When NPs work in collaboration with a physician, they have the ability to bill “incident-to” the physician in long-term care (LTC) settings other than SNFs, such as assisted living facilities, home, and office practices. The “incident-to” billing rules provide an exception, allowing 100% reimbursement for nonphysician services that meet the requirements detailed in the Medicare Benefit Policy Manual.5
There are six basic requirements6 to meet the incident-to guidelines for Medicare payment (Box 1).
Services meeting all six requirements may be billed under the supervising physician’s national provider identifier (NPI), as if the physician personally performed the service. Documentation should detail who performed the service and that a supervising physician was in the same office suite (although not necessarily the same room), at the time of the service.
It is important to remember, though, that incident-to applies only to Medicare, as commercial payers have their own rules, many of which do not permit incident-to billing. This is actually the direction that Medicare is going as well. The change would save millions of Medicare dollars each year and make nonphysician provider contributions more transparent.
Recently a group of expert policy advisors to the Secretary of Health and Human Services voted unanimously to recommend eliminating incident-to billing for APRNs and physician assistants (PAs) in Medicare. If adopted, this new recommendation from the Medicare Payment Advisory Commission (MedPAC)7 would no longer permit the incident-to billing option, meaning that NPs could only bill Medicare directly for all the services they provide.
Depending on the state’s designation of the NP’s scope of practice, some can now serve as an attending PCP within the SNF. However, in most situations, Medicare requires that the initial visit (history and physical) must be performed by a physician for the purpose of certifying that the patient requires skilled care. An NP may, however, make a “medically necessary” visit without an initial physician visit; this could occur when a newly admitted Medicare patient in an SNF develops a problem that requires medical evaluation and intervention, before being seen by the physician. All subsequent visits may be performed by an NP (or other nonphysician), alternating with the physician.
NPs may perform the initial history and physical for new LTC (nonskilled) admissions. NPs may also make additional visits, which must be substantiated based on the patient’s need (ie, acute illness). Medicare provisions permit 1.5 visits per month; more than this frequency may invite increased scrutiny in the form of an audit.8
SNF Employment and Beyond
Given NPs sole or primary dedication to the SNF, they are more available than most attendings to quickly assess and care for any urgent matter that may arise and by doing so reduce hospitalizations and potential liability issues. In addition, they can serve in an educational role for the entire facility. By providing staff education, the entire skill set of the SNF can be raised.
To help support their time within an SNF, many are opening a separate outpatient geriatric clinic located in the SNF. This not only provides revenue but also gets the community’s older adults to form a positive relationship with the SNF, so that, when they need skilled care, they will think first of that SNF and thus also serve as a new referral source. Also, in this type of clinic, they can still bill incident-to a physician when a physician is present in the building to provide direct oversight in keeping with the rules previously mentioned.
The role of NPs in LTC is incredibly bright as the shift to value-based care will increase the need for greater primary care services in SNFs—a role NPs are well suited to fill. Once secure in the position as attending PCP in SNFs, it is almost certain that there will be a move to expand their ability to serve as medical directors for SNFs; however, such a significant a change may take an act of Congress rather than simply an administrative fix. This final expansion of the NP role in SNF may take some time, but it will surely come at some point, perhaps starting in assisted living facilities where that strict requirement does not exist.
1. Association of American Medical Colleges. 2019 Update, The Complexities of Physician Supply and Demand: Projections from 2017 to 2032. https://aamc-black.global.ssl.fastly.net/production/media/filer_public/31/13/3113ee5c-a038-4c16-89af-294a69826650/2019_update_-_the_complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf. ublished April 2019. Accessed June 4, 2019.
2. Agency for Healthcare Research and Quality. The number of nurse practitioners and physician assistants practicing primary care in the United States. https://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.html. Published September 2012. Reviewed September 2018. Accessed June 4, 2019.
3. Nurse practitioner salary in the United States. salary.com website. https://www1.salary.com/Nurse-Practitioner-Salary.html. Accessed June 4, 2019.
4. Health Resources and Services Administration; Scope of Practice Policy. Nurse practitioners overview. scopeofpracticepolicy.org website. http://scopeofpracticepolicy.org/practitioners/nurse-practitioners/. Accessed June 4, 2019.
5. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15—Covered Medical and Other Health Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. Revised February 1, 2019. Accessed June 4, 2019.
6. Verhovshek GJ. The basics of incident-to billing. Physicians Practice. November 24, 2016. https://www.physicianspractice.com/medical-billing-collections/basics-incident-billing/page/0/1.
Accessed June 4, 2019.
7. Firth S. MedPAC recommends killing ‘incident to’ billing. MedPage Today. January 18, 2019. https://www.medpagetoday.com/publichealthpolicy/medicare/77528. Accessed June 4, 2019.
8. Lusis SA. Medicar reimbursement for nurse practitioners in long-term care [CME]. Medscape. https://www.medscape.org/viewarticle/464725. Accessed June 4, 2019.