Captain of the Ship doctrine and NPs.

[cessnadriver]

Hello all, I have been informed in another thread by a PA that NPs can now practice independently. As the thread was approved by a moderator I assume is an NP or CRNA, this appears to be the truth. My not knowing this caused me to make a misstatement about NPs.

My question is now that you can practice without a collaborative agreement, ie independently, how has this affected the price of you professional Liability Insurance. And will " Captain of the Ship" doctrine of legal defense still hold true for those of you not independent paractioners?

Thank you in advance for any replies and information.

[core0]

I understand reimbursment for CRNAs as I have been a CRNA for many years. My question is now.. WHY are not NPs reimbursed 100% of the physician rate ?.. Are PAs? If not, why not? are not all APNs equal?

I was informed in this forum that NPs could practice autonomously. If they can do this I would expect reimbursment to be done on exactly the same model as that used for CRNAs.

Both PAs and NPs are reimbursed the same. When I speak about reimbursement I am talking for the most part about Medicare reimbursement. For private payors most reimburse at 100% of the physician rate when billed under the physician. NP and PA owned practices must contract seperately with each private payor and in many states there is no requirement to contract with a given provider or pay all providers equally.

For Medicare the payment system evolved over the years as Medicare evolved. PAs and NPs were included in the original Medicare payment legislation but mostly in terms of rural services. Into the 90's the system evolved such that PAs and NPs were paid between 65% and 85% for services in rural areas, nursing homes, and surgical assisting. They were also reimbursed 100% for providing incident to services in all areas. The balanced budget act of 1997 equalized the rules across all environments. It provided for reimbursement at 85% for all services and 100% for incident to services. It also allowed NPs to directly bill Medicare.

The reason for the 85% rate is a little harder to tease out. In one sense it was the rate that existed before the BBA 1997. There were proposals to increase the rate to 97% of the physician rate during the hearings for the bill. Given that Medicare reimbursement is a zero sum game, that idea had little traction. The reasons for the 85% are somewhat lost to history. On of the reasons that I have heard is that during the 70's and 80's as Medicare payment expanded PAs and NPs were being touted as a lower cost alternative to the physician. This led to the deduction.

The explanation that appears to be supported by the Congressional record is a little more complicated. Physician compensation is based on Relative Value Units (RVUs). An RVU is composed of three components

1. Physician work component which measures time skill and intensity associated with the service provided.

2. Practice expenses which measure such things as office rents and employee wages.

3. Malpractice expenses.

There are references to the NPPs in the record in regard to RVUs and that the discount was arrived by evaluating these three items which arrived at a RVU of 85% for the NPP.

NPs and PAs that own their own practice make similar money to physicians in the same area. The difficulties they face relate mostly to contracting with private payors.

CRNA salaries are largely the result of the profession being able to leverage TEFRA billing into direct billing by CRNAs. In addition the billing formula used for anesthesia has significant discordances over the the RVU system used by the rest of medicine.

David Carpenter, PA-C

[al dente]

I'm a psych NP and reside in an independent practice state. I practice completely autonomously in both my private practice and at a local psych hospital where I work 2 days/week and occasional weekends. I function in essentially the same capacity as a psychiatrist.

I am also a clinical psychologist and can bill both Medicare and Medicaid independently for my services. I don't know if this is possible because I am also a psychologist and I have never inquired with CMS about this, but reimbursement has never been an issue. My Medicare/Medicaid billings are minimal, however, as most of my patients are self-pay in my private practice. I don't know exactly how the hospital reimbursement works, and it is possible that the hospital bills under an MD for my services - I have not inquired about this. They pay me hourly and that is all I typically pay attention to. But, no MD reviews, co-signs, or is otherwise involved with my charts or patient care.

As far as malpractice insurance rates, they do not rise based on your level of autonomy or expanded scope of practice. Rates are based on actuarial data, meaning that malpractice rates will only increase if the rate at which a provider is sued increases. In fact, my malpractice rates as a psych NP are lower than my malpractice rates as a psychologist.