Should nursing charges be separate from the room charges?

  1. I have been wondering about this for a long time. Nursing services are routinely included in the room charge for patients. Now we all know that some patients require A LOT more nursing care than others. But the room charges are the same. Doctors charge for each procedure they perform so why shouldn't hospitals charge for nursing services? Such as foley cath insertion/change, dressing changes, IV starts, NG insertion and so on? The ER charges based on level of care provided, so why not other departments? This has always baffled me. Any thoughts anyone?
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  2. 34 Comments

  3. by   altomga
    My co-workers and I have discussed this same subject. I do think that nurses should be able to charge for certain things. Some stuff increases our workload, decreases time able to spend with other patients and CAN ONLY BE DONE BY A NURSE!!
    The respiratory therapists at my hospital charges for everything. From oxygen therapy, each neb tx given, ABG draws, intubation, extubation, etc.....
    If they can charge and doctors charge for just visiting the patient, why can't nurses charge for procedures and treatments?

    The administrators try to say that since the floor I work on charge more for the rooms than does the general care floors that makes up for the nursing care required. But lets think, the nurses on my floor do not make any more compensatory money for working there than the general care nurses.....sounds like a load of BS to me

    Don't get me wrong, I don't think I should make more (or extra for working an ICU floor) than a general care nurse (they work their tails off too!!) But we ALL should be able to charge fees for "certain" procedures, etc.....
  4. by   deespoohbear
    Hey, I didn't even think about the respiratory department and their charges!! They do charge for all that stuff. Now I am feeling slighted.

    I believe that if nursing started to charge for nursing procedures maybe nurses would have more ground to stand on when it came to salary and benefits. I don't know. It doesn't seem fair that some of the patients only require a minimal amount of my time and other patients require lots more but they all pay the same.
  5. by   whipping girl in 07
    I agree that nursing procedures, assessments, etc. should be billed separately. The room charge should be exactly that, for a room, and the charge for a Tylenol should be hospital's cost plus a little for profit, instead of including nurses salaries in the charges for supplies.

    Every time you walk in that room there ought to be a charge. Maybe then people will realize how much the nurses actually do, instead of bytching because a box of Kleenex cost $17 on their hospital bill.
  6. by   NurseShell
    This makes perfectly good sense to me!! As far as I know the other depts. charge for each item/service (I used to do billing for the cardiology/neurology dept at a local hosp.) I assume patients are charged for the equipment (i.e. cath kit) so since it doesn't sit on their table for looks there should be a charge for it's insertion, care, etc! Right?! When acuity is calculated perhaps the "nursing charge" should coincide? Just a thought...
  7. by   ShandyLynnRN
    in our unit we have started doing our own charges... well part of them anyway.... for our OB patients, we charge individually for monitoring room, external monitor, internal monitor, sterile speculum exam, delivery charge per hour, labor induction per hour, electric breast pump, circumcision charges, oxygen per hour, radiant warmers per hour... lots more

    but there are many charges that AREN'T included like IV starts, etc.... was told that that is all included in the room charge. They DID increase our room charges though.

    Then patient accounts charges for other stuff too... all the stickers off of packages, and pharmacy charges for meds, and lab charges for lab etc...
  8. by   spineCNOR
    Excellent point, deespoohbear!

    Hospital administrators do not value the work that nurses do, in part, because we are part of the room charge. Perhaps charging for nursing procedures would give nurses more clout with mangement--most administrators (IMHO) would cheerfully replace nurses with unlicensed workers if they could. Putting an actual number figure on what we do might open their eyes a little bit.

    It actually seems very reasonable that a patient requiring a great deal of complex care should be charged more for nursing care than a patient that is not very time consuming. Perhaps patients could be charged a small basic room charge, and then every dressing change, IV start, nursing assessment, etc. would be extra.

    Advanced practice nurses (CRNAs, NPs) are generally regarded as professionals by administration, while the bedside nurse is not--is this in part because they can bill for their services?
  9. by   Edward,IL
    Wake up and smell the fiduciary coffee, ya'll. This is the BIG picture of hospital charges.
    1) Any department headed by a man gets to bill directly for their services (lab, x-ray, resp. therapy, pharmacy, physical therapy)
    Departments headed by women (nursing, dietary, housekeeping are thrown in with the room rate. This serves a couple of purposes. One, by structuring the accounting system this way, administration can say, "boy, you nurses are an expensive part of the overhead. This keeps the girls own at heel and feeling guilty that they are paid for what they should do willingly as part of their womanly duty. Two, if nursing costs were to be unbundled, that would put a value on Nursing professional services, and give value to the work nurses do.
    Three. In-patient hospitalization with the monitoring and care provided by nurses is the only reason that people are admitted. They would otherwise be seen as out-patients in their doctors office or have their procedure or diagnostic test done in ambulatory care.
    Four. Hospitals are not expensive to run, they just sort of serve as a giant money laundering operation. Large instituitions are usually built with tax-advantaged bonds, government money,etc. Operational costs are not that much. Did you know that city governments often times will not charge property taxes or even a water or sewer bill? It's politically advantageous to have a hospital in your city or allow one to expand to "create jobs" (horrible low-paying service jobs that only someone REALLY desperate for work would take!)
    Five. Consider this. The standarddaily room rate is about 1800-200 dollars. I could take a patient to a VERY nice hotel
    for < $200 per day with meals, linens provided, bill for nursing services at a rate of $30.00/hour for 24-hour private duty care (24 x 30 = $720 + $200.00=$900.00). At the hospital where you work, you care for an average of at least 5-10 patients at a time for an hourly wage of say $20.00. As a consumer, how can I be sure that I'm really getting my $4.00/hour worth of nursing care?
    Six. An excellent book on this subject that chronicles all of the many ways that nurse can be financially exploited is titled Hospitals, Paternalism and the Role of the Nurse, by JoAnne Ashley, published c. 1975. If you are going to work in a hospital, at least know to what degree that you're being taken advantage of.
  10. by   JNJ
    I was going to post, but then read that Edward, IL had done a much better job and included more points. Thanks Edward for a thought provoking posting.
  11. by   Gardengal
    I agree that it might seem insulting to be included in the room charge, but I sure don't want to be the nurse who has to jot down all my supplies and time and effort used at the bedside so that I can bill for it later...what a nightmare! Can you imagine the time and energy expenditure? Here's an example:

    Patient admitted to ICU in septic shock, hypotensive, intubated in ER, on multiple pressors, lots of anxious family, combative requiring sedation in order to treat. So..lets see what we would do:
    1 Get report
    2 Get patient into bed
    3 Attach to noninvasive BP, monitor and pulse ox
    4 Call resp therapy to attach and set up vent
    5 Page MD that pt has arrived
    6 check vs on monitor- decide if they're Ok or not
    7 Quick physical assessment for abc
    8 Get ER linens out
    9 Cycle BP for another set vs if they were relatively ok before if not you already rechecked them and dirty linens are still there....Call MD again so you can get orders to titrate pressor meds up, or get original order.
    10 draw labs
    11 enter labs in computer and send labs
    12 Get specimen collection containers and get sputum and urine cultures, send them.
    13. titrate pressors becaus of BP change
    14. Get ABG results back-call mD
    15. call respratory and make vent changes.
    16. set up for line insertion
    17 talk to family while assisting with line insertion so you can get more detail and get advance directive info.
    18. Do the assessment on paper after doing full physical assessment afetr line done
    19. I forgot preparing transducers and hooking up cables, zero, etc,
    20. sterile central line dressing
    21. cxr-call to have done, assist with film position
    22. call md to tell him film is done and needs viewed
    23. reposition endo tube and retape because in to far. (no wonder we needed so much sedation (forgot to mention titrating that too)
    24. ask nursing assistant to restock line insertion cart
    25 etc, etc, etc


    I personally don't want to keep track of all this so I can later bill for it-especially since we get a flat rate fee for at least half of our patients, and not item or fee charge reimbursement. I'd rather acknowledge that the fee charged for a bed in my area includes the services of nursing, housekeeping, electricity, plumbing, depreciation, case management, dietary, general supplies....etc. I also am glad that I do not save all those stickers off of items by wearing them until I can place them on a charge board so they can be charged...that was a pain.

    I would love to think that we could quantify our costs, but the time and energy involved in the nursing department, in addition to th efinance department doesn't seem worth it fo rmy ego's sake. I'd rather look at it as the daily charge is for the care and services, and you just happen to get billed for it as a room rate because that's where it happened.

    Sorry for the disjointed entry-got called to the phone half way through so didn't finish this lengthy(and some would say painful) post immediately and somehow sent it off before finishing.
    Last edit by Gardengal on Mar 5, '03
  12. by   deespoohbear
    Originally posted by Gardengal
    I agree that it might seem insulting to be included in the room charge, but I sure don't want to be the nurse who has to jot down all my supplies and time and effort used at the bedside so that I can bill for it later...what a nightmare! Can you imagine the time and energy expenditure? Here's an example:

    Patient admitted to ICU in septic shock, hypotensive, intubated in ER, on multiple pressors, lots of anxious family, combative requiring sedation in order to treat. So..lets see what we would do:
    1 Get report
    2 Get patient into bed
    3 Attach to noninvasive BP, monitor and pulse ox
    4 Call resp therapy to attach and set up vent
    5 Page MD that pt has arrived
    6 check vs on monitor- decide if they're Ok or not
    7 Quick physical assessment for abc
    8 Get ER linens out
    9 Cycle BP for another set vs if they were relatively ok before if not you already rechecked them and dirty linens are still there....Call MD again so you can get orders to titrate pressor meds up, or get original order.
    10 draw labs
    11 enter labs in computer and send labs
    ]

    Some of that stuff you really couldn't put a charge on. I am talking about actual procedures such as foleys, NG's, IV starts, lab draws, dressing changes, etc. Doctors, therapy, resp, lab, and xray get to charge for each procedure performed...so why not nursing?

    I think Edward has an excellent post about nursing being mainly females and most males in administration trying to keep the "girls down and out."

    Does anyone know if there is a hospital that charges for nursing procedures separate from the room charges? I would love to hear from you.....
  13. by   AlaskaKat
    We used to do a lot more individual supply and procedure charges and they all recently got chopped and batched into the room charge. the reason? Medicaid reimbursement... They won't pay for the procedures and practices they consider routine. Even breast pumps and circumcision, which certainly are not routine we can not charge for anymore.
  14. by   Gardengal
    I think that one of the reasons charges are higher for some of the items we use when we do bill for them is because it costs to use them-ie foley charges, ng, etc. -cost to hospital is way different than to the patient.

    I can't think how we could bill for the critical thinking which is what differentiates nurses from techs. One of our biggest frustrations is that we spin our wheels coordinating all sorts of activities all at the same time. Kind of tough to bill that to one individual. Easier to group it as a charge in toto.

    Perhaps we could differentiate nursing charges based on where a patient fits into an acuity scale, but I still see a data entry work increase...is it worth it?

    a couple of other points-I don't think it's a male female thing. Our pharmacy, pt and xray departments are led by women.

    Also, I recall reading a book years ago about paternalism with hospitals and vaguely recall this topic (probably the same book referred to by Edward)-I believe our health care environment has changed quite a bit since the publishing date of 1975. Afterall DRGs came out in the mid 80s-and finances have gone down since then.

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