Can NPs work as RN's? - page 2

We have a big debate going on right now, once I get my NP can I still work as a "regular" RN? or am I always going to have to take a job as an NP?... Read More

  1. by   tiredfeetED
    Quote from ibnathan
    Thanks Trauma just got back from graduation ceremonies time to party!:

    I know that our instructor was saying that when she went to go on an interview for a position at a MD medical group they offered her $35.00 an hour. She makes $45-50 dollars an hour per diem as an RN. She laughed and walked out I think for the schooling and responsibility that NP's have they should make anywere from $65-85 an hour. Just my thoughts.
    It is true of central cali, there are many APN working as staff RN. Wages are increasing daily as it is not unheard of to make 40/hr with bennies as a staff RN which is more the norm. My classmates from the Bay area make 60-65/8h 1.5 after 8h as staff RN (perdiem). The pt ratio laws and state prisons are driving up the wages ($96,000/yr with state bennies). For me, Midlevel provider is what i want to do.
  2. by   juan de la cruz
    Quote from tiredfeetED
    It is true of central cali, there are many APN working as staff RN. Wages are increasing daily as it is not unheard of to make 40/hr with bennies as a staff RN which is more the norm. My classmates from the Bay area make 60-65/8h 1.5 after 8h as staff RN (perdiem). The pt ratio laws and state prisons are driving up the wages ($96,000/yr with state bennies). For me, Midlevel provider is what i want to do.
    If the hospitals are willing to pay the RN's that much, can you give me a figure of how much they pay their hospital-based NP's?
  3. by   tiredfeetED
    I havent seen the hospitals use NPs in my area. The ER docs use midlevels. State prison pays NPs about 1k more/monthly than staff RNs.
  4. by   core0
    Quote from pinoyNP
    If the hospitals are willing to pay the RN's that much, can you give me a figure of how much they pay their hospital-based NP's?
    The reason that you don't see many hospitals employing NP's is economics. The RN salary is simply supply/demand. Not many nurses/lots of demand = high salaries. This is compounded when there are laws (California) or regulation (hospital rankings) that demand certain nurse staffing ratios.

    The NP situation is somewhat different. It is very difficult for a hospital to charge for NP services. There are rare cases where it may make financial sense to hire an NP for certain services. Also it may be helpful for a hospital to hire an NP to retain certain physician services. Here though there is not as much competition and there is no income to offset the salary. Also remember that many NP's are salaried as opposed to staff nurse which are hourly (a source of additional income). I have actually seen cases where if you took an hourly rate for the NP they are below the pay for a staff nurse.

    David Carpenter, PA-C
  5. by   mvanz9999
    Quote from traumaRUs
    mvanz999 - you are correct $35 is pretty good money for an APN in IL. However, our state is home to the AMA which keeps our salaries artificially low.

    Well, that sux! I have no desire to live in CA though.

    Hm....

    Why do they keep the NP salaries artificially low? So there's no competition for the doctors?
  6. by   core0
    Quote from mvanz9999
    Well, that sux! I have no desire to live in CA though.

    Hm....

    Why do they keep the NP salaries artificially low? So there's no competition for the doctors?
    More likely more money for the doctors. Most NP's work for medical practice. I have not seen any absolute statistics, but I would guess less than 10% of NP's own their own clinics. Most of these are rural health clinics that have limited income (although the Advance salary profile shows that NP's that own their own clinics make the most). So if you are working as an employee, their is a strong incentive to keep salaries down. Look at it this way, there is no increased income from paying an NP more, only increased cost.

    David Carpenter, PA-C
  7. by   traumaRUs
    The whole thing boils down to how much money can an NP bring to their practice or facility. I work for a private practice and I bill at 85% of the MD rate (can't change that - that's CMS regs). So...I have to see higher volume than MD's in order to bring in revenue.

    Dialysis patients are to be seen four times per month per CMS (Medicare). So...the MD sees the pt once per month and then I see them the other 3 times and that way our practice can bill the max allowable charges.

    I use this as an example only - its the bottom line!
  8. by   mvanz9999
    Quote from traumaRUs
    The whole thing boils down to how much money can an NP bring to their practice or facility. I work for a private practice and I bill at 85% of the MD rate (can't change that - that's CMS regs). So...I have to see higher volume than MD's in order to bring in revenue.

    Dialysis patients are to be seen four times per month per CMS (Medicare). So...the MD sees the pt once per month and then I see them the other 3 times and that way our practice can bill the max allowable charges.

    I use this as an example only - its the bottom line!
    So do you have a link to another post where you describe what you actually spend your day doing?
  9. by   juan de la cruz
    Quote from core0
    The reason that you don't see many hospitals employing NP's is economics. The RN salary is simply supply/demand. Not many nurses/lots of demand = high salaries. This is compounded when there are laws (California) or regulation (hospital rankings) that demand certain nurse staffing ratios.

    The NP situation is somewhat different. It is very difficult for a hospital to charge for NP services. There are rare cases where it may make financial sense to hire an NP for certain services. Also it may be helpful for a hospital to hire an NP to retain certain physician services. Here though there is not as much competition and there is no income to offset the salary. Also remember that many NP's are salaried as opposed to staff nurse which are hourly (a source of additional income). I have actually seen cases where if you took an hourly rate for the NP they are below the pay for a staff nurse.

    David Carpenter, PA-C
    There's some truth to your remark for hospitalist NP's who only do H&P's and progress notes. But even those NP's can bring revenue to a hospital. I belong to a group of critical care NP's hired under our Department of Surgery's Trauma and Critical Care Services. We manage patients in the cardiothoracic surgery ICU and perform invasive procedures in addition to H&P's, consults, and daily ICU notes. We charge for each A-line, central line, chest tube, Swan-Ganz we put in. Our H&P's and progress notes are way more detailed than senior ICU staff. We have gotten kudos from our coders because they can get the highest revenue codes for our documentation and this translates to higher profits despite the fact that we can only claim 85% of the fee. I think it's all a matter of spreading the word to physicians about what we can do. Our collaborating physician has been such a great advocate for NP's. She even helped us with strengthening our case for a raise and yes, she is a female surgeon and the most awesome one I've met!
    Last edit by juan de la cruz on Dec 18, '06
  10. by   mvanz9999
    Um....can I have your job?
  11. by   core0
    Quote from pinoyNP
    There's some truth to your remark for hospitalist NP's who only do H&P's and progress notes. But even those NP's can bring revenue to a hospital. I belong to a group of critical care NP's hired under our Department of Surgery's Trauma and Critical Care Services. We manage patients in the cardiothoracic surgery ICU and perform invasive procedures in addition to H&P's, consults, and daily ICU notes. We charge for each A-line, central line, chest tube, Swan-Ganz we put in. Our H&P's and progress notes are way more detailed than senior ICU staff. We have gotten kudos from our coders because they can get the highest revenue codes for our documentation and this translates to higher profits despite the fact that we can only claim 85% of the fee. I think it's all a matter of spreading the word to physicians about what we can do. Our collaborating physician has been such a great advocate for NP's. She even helped us with strengthening our case for a raise and yes, she is a female surgeon and the most awesome one I've met!
    I don't understand how you can charge for seeing the patients. If I understand the Physicians are hospital employees (or more likely employed by a physician group that has a contract with the hospital) then they have already been payed to see the patient when they did the surgery. Depending on the surgery there is a 30 or 90 day global period that is covered by the surgical fee. If you did not do surgery and are continuing to follow them (not uncommon with trauma services) then only one person from the service can charge. If they are part of the same service then you can us Co-billing with medicare to increase your charges. You can over course charge for any procedures that you do. If you are in the same service and you and the physician are charging for services this is double billing (if I understand the relationships).

    Also on the subject of billing. The 85% rule only applies to Medicare patients. If they are not medicare (medicaid has its own rules) then you bill at whatever rate you have negotiated with the insurance company. If you do not have a contract with the insurance company it is the usual and customary rate. This also applies to medicare HMO's and PPO's. There are very few people with straight medicare or medicare primary after medicare part D came out. We collect the physician rate for PA services in my practice for new patients and consults that are not medicare (unless there is specific PA/NP language in the contract.

    David Carpenter, PA-C
  12. by   juan de la cruz
    You may not have understood from my post that our role involves managing ICU patients who underwent heart and lung surgery. We work under collaboration with the intensivist in the CTSICU (who happens to be a surgeon who underwent further training in trauma and critical care). That's why we are under Trauma and Critical Care Services and not Cardiothoracic Surgery. ICU patients need an ICU admission consult and daily ICU notes - that's a requirement for all ICU patients regardless of what insurance they have. These notes are signed by the intensivist during rounds but if it is an NP that completed the documentation, it is billed under the NP and not the physician, that is what the regulations say.

    As far as procedures, I don't undesrtand how you can overcharge when you do procedures individually. The same applies to these procedures as I've said above - if the NP did them, even if the MD signed the procedure note, it is billed under our name.

    You're right the CT surgeons do not need to write notes daily although they do round with us every morning with the intensivist. We don't work for the CT surgeons, we just watch their patients - get it?

    I am aware of the 85% rule only applying to Medicare patients. What do you think is the biggest bulk of payer source for the CT surgery population? They are mostly over 65 and on Medicare! As for the younger patients, we still win because even if the notes were billed under the physician, they are detailed and are billed at the highest possible code. The intensivist did not spend as much time as we did writing those notes, we did, but in the end the hospital receives revenue for them so we all win.
    Last edit by juan de la cruz on Dec 18, '06
  13. by   core0
    Quote from pinoynp
    you may not have understood from my post that our role involves managing icu patients who underwent heart and lung surgery. we work under collaboration with the intensivist in the ctsicu (who happens to be a surgeon who underwent further training in trauma and critical care). that's why we are under trauma and critical care services and not cardiothoracic surgery. icu patients need an icu admission consult and daily icu notes - that's a requirement for all icu patients regardless of what insurance they have. these notes are signed by the intensivist during rounds but if it is an np that completed the documentation, it is billed under the np and not the physician, that is what the regulations say.

    ok i understand what you are doing. we don't use too many surgical intensivists around here. mostly the ct surgeons handle their own patients and call in medical intensivists for medical issues. there is a method that you can use to increase the billing if you want. this is called co-billing. the only thing that you need to do differently is to have the physician participate in any part of the care plan. for example they can do their own physical exam or they can discuss the care plan with the patient - just need to document it. then you can bill under the physician id at 100%. for example the physician can write, "i discussed the plan of care with the patient and answered questions about x". just need to do more than signed and reviewed.

    as far as procedures, i don't undesrtand how you can overcharge when you do procedures individually. the same applies to these procedures as i've said above - if the np did them, even if the md signed the procedure note, it is billed under our name.

    you can't i was referring to the rounding. i don't have much experience in this, but my understanding is that you bill under your provider number.

    you're right the ct surgeons do not need to write notes daily although they do round with us every morning with the intensivist. we don't work for the ct surgeons, we just watch their patients - get it?

    that would be hospital policy on writing notes. medicare still expects them to provide follow up care. who follows these patients on the floor?

    i am aware of the 85% rule only applying to medicare patients. what do you think is the biggest bulk of payer source for the ct surgery population? they are mostly over 65 and on medicare! as for the younger patients, we still win because even if the notes were billed under the physician, they are detailed and are billed at the highest possible code. the intensivist did not spend as much time as we did writing those notes, we did, but in the end the hospital receives revenue for them so we all win.
    good notes are helpful for documentation for charges, but they are just to support the level of care. the level of care is really determined by the medical decision making, level of complexity and coordination needed. also if you spend a lot of time educating/counselling the patient you can code by time if counseling >50% of the time. i find thats one part that many providers forget.

    david carpenter, pa-c

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