Graduating December 2019, looking for advice

Trauma Columnist · May 5, 2019

I apologize for not getting back to this thread.

So here is my take on nephrology for APRNs:

We are very lucrative for the practice:

1. We can bill for all those chronic outpt dialysis center visits. CMS allows APRNs to bill for the 4 visits. The exact reimbursement is:

Medicare Allowable 4 visits: $284.00 2 visits: $238.00 1 visit: $183.00

You get no extra money for the third visit so its best to get 1 or 2 or 4 visits.

So, in a large practice, you can see that APRNs would be big money makers. For instance: I have approx 150 pts I see per month. On average, I see 130 for 1 visit billed at 85% of the MD rate = $155.55 per pt per month = $20,221 per month revenue x 12 months = $242,658. Now I don't make $242,658. However, when I factor in my salary, benefits I am still pretty profitable. The scenario above is the absolute minimum I produce per month. Most of the time I get all 4 visits. Our metric is to attain 90% of all of our pts being seen 4 times/month for the maximum revenue.

2. Travel is involved for most practices, some more then others. In our practice, we have 8 APRNs doing outpt HDU rounding. We cover a large portion of the state so most of us travel daily - ranging from zero travel (for an APRN with one very large unit) to me who travels to 4 smaller clinics each approx 40 miles from the other in a rural setting.

3. There are other revenue streams as well: completing POLST forms and discussing end of life issues - advanced care planning is reimbursable for ARPNs once per year.

4. In-office care/education to consist of CKD education is also billable.

5. Transition from hospital is also a money-maker though not so much as in-center HDU visits. However, it frees up the MD to do more of the high-dollar care/procedures.

6. Since we handle a lot of the in-center HDU care of pts, we also are required to be ACLS certified. These pts are sick and yes, sudden cardiac death is a real occurrence.

7. We do a lot of end of life and quality of life family meetings and because we see the pt so often, we are often the bridge to their families in telling the family that Mr Smith is stating he doesn't have much of a quality of life anymore and wants to stop but Mr Smith needs support to express this to his family.

Its not all about being billable but you must be aware of your worth. Research has proven that the care of APRNs does improve outcomes as to the amount of time we can spend with patients. Its also a huge patient satisfier that we see the patients once per week. Not every week do we do major "things" for the patient but for many HD patients, expressions of of sincere care is what they need. We also do prior authorizations (of which there are many) and serve as a resource for the in-center social workers, dieticians and nurses. Many of the nurses feel very comfortable talking with another nurse versus calling the doctor so we do provide education for them as well in some areas.

Nephrology and especially HD care, often opens the door to consulting with other providers and that is a good thing because coordination of care between providers is really important in the HD population.

Hope this answers some of your questions. If I can answer something else, please let me know and I will try to be more timely.

Mr. Southern NP, MSN, APRN, NP · May 6, 2019

@traumaRUs

It's quite alright, I never expect instant feedback at this point in my career and life. I have trained myself to be pretty patient.

I understand that NPs can be lucrative for nephrology and combining that fact with the fact that I have been working in HD for 8 years seems to naturally lead me in that direction. My hope through conversing with you is to determine how lucrative I can market myself to be, as well as get an honest feel for the position itself.

Now to respond to your points:
1: If my calculations are correct, if you are able to complete all 4 visits on 90% of your patients, you would be generating $391,068 just from outpatient HD visits. I know for most practices in our area (Georgia), the physician sees the patient for the first visit of the month, then, either another physician, NP, or PA tries to complete the other three. I'm not 100% sure if that is a regulation in GA, or if it is more of a "just the way things are done" situation. I'll have to do more digging to find that out.

2: I definitely understand the travel necessities. One question regarding that: do you get reimbursed for mileage, or is it considered a part of the expectations of the position and factored into salary? The practice I am hoping to onboard with covers a similar area to the one you describe.

3: This is interesting to know as an additional source of revenue that APRNs can contribute to the practice.

4: The practice I'm hoping to join hosts monthly education classes for AKI/CKD patients. Currently one of the physicians is the instructor for the class.

5: Would this be the TOC visits post-hospitalizations in-center or in-office?

6: I was ACLS certified while working in the hospital, but haven't been since being in HD. I have experienced the full gamut of events that could occur during HD and wouldn't expect re-certifying for ACLS to be too foreign.

7: This is a natural expectation moving into the APRN role. I have been through many difficult conversations with patients and families.

Thank you for your response, it has covered a great deal of my questions. There might be a few more I have to ask, but some might be more appropriate for a private message. Thanks, again.

Trauma Columnist · May 6, 2019

1: If my calculations are correct, if you are able to complete all 4 visits on 90% of your patients, you would be generating $391,068 just from outpatient HD visits. I know for most practices in our area (Georgia), the physician sees the patient for the first visit of the month, then, either another physician, NP, or PA tries to complete the other three. I'm not 100% sure if that is a regulation in GA, or if it is more of a "just the way things are done" situation. I'll have to do more digging to find that out.

CMS is the payor of in-center HD pts as all pts with ESRD are entitled to Medicare at least for HD UNLESS they have never worked. Children under the age of 18 get Medicare automatically if they have a diagnosis of ESRD.

As to my math - since the MD usually does one visit (if the pt is compliant and/or not hospitalized on the day of the MD visit)I tried to factor that in also. APRNs bill at 85% of the MD rate, so my figures are on the low side. APRNs CAN do all 4 visits but then they receive only 85% of the total. (It is complicated)

2: I definitely understand the travel necessities. One question regarding that: do you get reimbursed for mileage, or is it considered a part of the expectations of the position and factored into salary? The practice I am hoping to onboard with covers a similar area to the one you describe.

Yes, I get reimbursed for mileage. The way it works for us is you have a "home" unit. My "home unit" is 20 miles from my house so I zero my odometer at the start of the day and when I hit my driveway at the end of the day, I take away 40 miles and thats my total of reimburseable miles per day.

4: The practice I'm hoping to join hosts monthly education classes for AKI/CKD patients. Currently one of the physicians is the instructor for the class.

Better revenue stream to have APRN do it...then MD is freed up to do higher paying procedures or to see more complex pts in office

5: Would this be the TOC visits post-hospitalizations in-center or in-office?

In-office though you could do them in-center on off-HD day. Also, the ESCO program offers another way to increase revenue. Its a pay-for-quality program. Here you go.

6: I was ACLS certified while working in the hospital, but haven't been since being in HD. I have experienced the full gamut of events that could occur during HD and wouldn't expect re-certifying for ACLS to be too foreign.

Yeah not a big deal - you just have to realize that as the APRN you are the one in charge during a code until EMS arrives

7: This is a natural expectation moving into the APRN role. I have been through many difficult conversations with patients and families.

Good. Many times the difficult conversations start with the HDU nurses/techs.

Best wishes...let me know via PM if you have any other questions. I won't ask where you are located but that might influence my answers too.

Mr. Southern NP, MSN, APRN, NP · May 6, 2019

2 hours ago, traumaRUs said:
CMS is the payor of in-center HD pts as all pts with ESRD are entitled to Medicare at least for HD UNLESS they have never worked. Children under the age of 18 get Medicare automatically if they have a diagnosis of ESRD.
Totally understand this part. I have tried to learn as much of the business side of ESRD as I can over the years.
As to my math - since the MD usually does one visit (if the pt is compliant and/or not hospitalized on the day of the MD visit)I tried to factor that in also. APRNs bill at 85% of the MD rate, so my figures are on the low side. APRNs CAN do all 4 visits but then they receive only 85% of the total. (It is complicated)
I understand. There are a lot of things that can complicate the in-center visits (compliance, hospitalizations, patient getting called in early or switching days, etc.). I was just calculating based off the theoretical scenario.
Yes, I get reimbursed for mileage. The way it works for us is you have a "home" unit. My "home unit" is 20 miles from my house so I zero my odometer at the start of the day and when I hit my driveway at the end of the day, I take away 40 miles and thats my total of reimburseable miles per day.
Good to know.
Better revenue stream to have APRN do it...then MD is freed up to do higher paying procedures or to see more complex pts in office
Sounds like a marketable asset.
In-office though you could do them in-center on off-HD day. Also, the ESCO program offers another way to increase revenue. Its a pay-for-quality program. Here you go.
Interesting.
Yeah not a big deal - you just have to realize that as the APRN you are the one in charge during a code until EMS arrives
At our rural center, there is no office for a physician, NP, or PA. They only round on patients here. So I'm the one in charge of codes until EMS gets here anyway. I wonder if that means that the RNs should be ACLS certified to cover for that?
Good. Many times the difficult conversations start with the HDU nurses/techs.
Best wishes...let me know via PM if you have any other questions. I won't ask where you are located but that might influence my answers too.
Thanks a lot for your help. Since I'm a rookie to posting on the site, I am unable to send you private messages at this time. I will once I am able though.

Trauma Columnist · May 7, 2019

As to the RNs being ACLS certified, at least in the big two companies they do not require it.

Mr. Southern NP, MSN, APRN, NP · May 7, 2019

And I'm with one of the big two. Glad I have ICU experience with all I've encountered in-center.

Trauma Columnist · May 8, 2019

Right - good point. I got this job with NO nephrology experience at all and beat out 5 other candidates, some with nephrology experience only because my nursing background is all Level 1 trauma ED and ICU.

Its always a good idea to remember critical thinking skills....lol