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NP owned practice business plan project for grad school - Medicare question

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Specializes in ICU.

Hey everyone,

I am doing a business plan project for my MSN class. I am a little confused at the whole Medicare reimbursement part of it. I have a book here to reference and have spent lots of time searching online, but I'm not really understanding how it all works.

If an NP were to open a clinic, would she be able to bill Medicare directly for services rendered if there weren't a physician on staff? Would it be sufficient to have a collaborating physician or a physician as a consultant? I read in my book here that in order to bill Medicare, the physician has to be in direct supervision of the NP.

If anyone could help me figure out how to set this up for my business plan project, I'd be VERY grateful. The whole thing is giving me a headache.

Thank you so much.

imanubee

Specializes in ICU.

If an NP were to open a clinic, would she be able to bill Medicare directly for services rendered if there weren't a physician on staff?

Yes you can bill directly without a doc on staff.

Would it be sufficient to have a collaborating physician or a physician as a consultant?

Yes

I read in my book here that in order to bill Medicare, the physician has to be in direct supervision of the NP.

Only if the NP is employed by the group AND is billing "incident to" the physician's services. Also, realize that different Fiscal Intermediaries determine Medicare policy for their region. So Medicare policy in Texas may not be the same Medicare policy in California. Your book's authors may very well have obtained their info from an FI w/ that restriction, but most likely that info is just dated. An NP does NOT have to be employed by or supervised by an MD to bill Medicare. To be sure though, you could go to the FI's website for your state and obtain the info straight from the horse's mouth. This will be exactly what you do once you enter practice to find the billing guidelines that you'll have to follow. Or just hire an experienced practice administrator to guide you ;-)

You would need a collaborative agreement in both practice setups---whether your own practice or whether employed by a group. This is not the same thing as a supervisory agreement. The billing details come into play once you decide HOW you are going to practice. If employed by a group, then initial decisions have to be made regarding the doc's and NP's expectations/roles, ie are you going to have you own patient panel and be just another provider in the group OR is the doc going to see the patient initially or for any new problems and then you take over care. This determines how Medicare is billed and also impacts reimbursement.

HTH!

Edited by imanubee

Hey everyone,

I am doing a business plan project for my MSN class. I am a little confused at the whole Medicare reimbursement part of it. I have a book here to reference and have spent lots of time searching online, but I'm not really understanding how it all works.

If an NP were to open a clinic, would she be able to bill Medicare directly for services rendered if there weren't a physician on staff? Would it be sufficient to have a collaborating physician or a physician as a consultant? I read in my book here that in order to bill Medicare, the physician has to be in direct supervision of the NP.

If anyone could help me figure out how to set this up for my business plan project, I'd be VERY grateful. The whole thing is giving me a headache.

Thank you so much.

The short answer is that it depends on the state. Medicare requires you to have a collaborating physician to bill. However, the level of collaboration is dependent on what is required by state law.

From a business standpoint there are three levels of collaboration. Supervision requires a direct relationship with the physician. In most states the NP cannot hire a supervising physician directly. However, the physician can be hired by a company where both are employees (and the NP is the owner). In states that require a collaborating physician, there usually needs to be a written agreement as to the collaboration. Again depending on the state the NP may be able to hire the physician directly or may have to use the method above. Finally in states that do not require collaboration medicare still requires it. However, in this case it may be as simple as documenting the NPs scope of practice and physician resources for cases outside the scope of practice.

As long as the requirements for Medicare are met (collaboration, scope, degree, and licensure) an NP can bill for anything that a physician would receive payment for.

Here are a couple of articles by Carolyn Buppert (probably the foremost expert on this) - Medscape registration required:

http://cme.medscape.com/viewarticle/562664_3

http://www.medscape.com/viewarticle/705683

And and article from PND:

http://www.physiciansnews.com/business/403burke.html

David Carpenter, PA-C