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Reimbursement Question


I have a few questions that some people seem to have different answers to and was wondering if you could assist me with this.

How does the reimbursement work for midleves, both PAs and NPs? Some people tell me that PAs seem to get 85% of the reimbursement and sometimes not even that since the physician has to cosign the chart and per this they charge a percentage of that. The NPs being independent practitioners, they seem to get more reimbursement since the physicians dont need to cosign the chart, thus , not charging a percentage. What is the truth behind this?

I read the legislation for Independence for NPs, thanks for letting me know about it. I know that CMA has a lot of opposition to it and last time it was on legislation it didnt go through; do we think it might be different this time?

I am simply to weigh my option and I know you are the right person to ask do to all of your experience and knowledge. I am a California Resident and I know that SB 323 is currently in legislation. Also, how is the reimbursement different where NPs have actually full autonomy of practice?

Thanks again,

lhflanurseNP, APRN

Specializes in Adult Nurse Practitioner. Has 40 years experience.

Medicare, thus many commercial insurers, pay NPs and PAs 85% of the allowable charge, while MDs and DOs get 100%. Even in areas with full autonomy, this is the fee schedule through Medicare. Funny...the ACA was supposed to stop discrimination and Medicare is a federal insurer!

Medicare a NP can boll 85% of physician fees. But medicare only pays 80% of billed. So say a procedure had a medicare fee schedule of $100.00. The MD would collect $80.00, a NP would collect $68 (85*.8). The rest of the amount is the patients or secondary insurance responsibility. Now if the patient has medi-cal as a secondary you will not receive additional funds since the medicare payment is already higher than medi-cal payments.

Some PPO and HMO plans will contract with a NP, some will not. If a state has a any willing provider law passed it makes it much easier to receive payment.