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Summary of Reimbursement Options
Under Medicare Law
Option #1: Nurse Practitioners Acting in an Independent Practice
(The 85% Option)
Nurse Practitioners in many states across the country now have the ability to bill Medicare directly irrespective of geographic setting. As the conference report notes, payment will “equal” 80% of the lesser of either the actual charge or 85% of the fee schedule amount for the same service if provided by a physician.”
An independent nurse practitioner operating in a state with NP friendly collaboration requirements will be able to bill Medicare directly for his/her services and all of the ancillary services provided to a patient “incident to” the NP’s representation.
For more on this issue visit ANA’s website for its section on: HCFA: Making Sense of the New Reimbursement Laws: Q & A
Option #2: Nurse Practitioner Employed by a Physician
(The 100%, 85% or 0% Options)
A. When a Physician is Present
(100% Reimbursement)
In instances where a nurse practitioner is employed by a physician, a physician will still be able to bill 100% of the Medicare fee schedule for services performed by the nurse practitioner. Physicians’ ability to bill 100% for a NP’s services, however, is predicated on meeting the requirements of the “incident to” rule which requires that a physician be “in the office suite” or “readily available” to provide assistance.
B. When a Physician is Not Present In States with Friendly Collaboration Requirements
(85% reimbursement)
When a NP is operating in a state with NP friendly collaboration requirements and the physician is not present in the office suite, the employee nurse practitioner may bill 85% for any reimbursable services he/she performs.
C. When a Physician is Not Present In States with Restrictive Collaboration Requirements
(No Direct Reimbursement)
When a NP is operating in a state with restrictive collaboration requirements, the nurse practitioner will still be unable to bill Medicare directly for his/her services.
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