Provider billing practices for office visits

[French]

Is anyone aware of health carriers providing different levels of reimbursement for office visits depending upon who provides the service (MD, NP or PA)? An employee addressed this question to us which in turn we relayed to our HMO carrier. Their response was that it was an industry wide practice to compensate at the same rate irrespective of who provided the service and that the CPT code does not differentiate between an MD, NP or PA for office visits. Any comments?

[mroberts]

I don't see why this wouldn't be the case. You could argue that it would make sense that services provided by a doctor should be more expensive than a nurse, however, that's not the way managed care works.

[Jbentz]

I am not a billing expert, but I can tell you that the cpt codes used for office visits are based on other factors, not on WHO performed the exam. It is not any cheaper to be seen by a nurse, nurse practioner, etc.... because a doctor must oversee, review and sign off on EVERYTHING that they do. So while you may see a NP for a cold, behind the scenes, the doctor is still reviewing the chart, approving meds and treatment, etc...

You are still getting their expertise and supervision whether you see them face to face or not.

Hope this helps.

[GBurns]

In some states including Florida NPs have their own offices and practice without a Dr reviewing charts or anything else. It is not necessary that "a doctor must oversee, review and sign off on EVERYTHING that they do". NPs DO NOT need a Dr. and their patients are not subject to "You are still getting their expertise and supervision whether you see them face to face or not". The reason for private practice etc of NPs is because they have the expertise and training necessary.

I think that you are confusing Nurses with NPs (it means Nurse Practitioner).

By the way, NPs are reimbursed by Medicare at 85% of the physician rate, Medicare in many states ranges between 85 and 92%. As a result there should be no problem with an HMO or PPO negotiating a different reimbursement schedule for NPs as opposed to FPs whose rates are less than those for Specialists.

While the CPT and ICD codes do not diffentiate, the contracted rates between the provider and the insurer or plan is different.

[Jbentz]

No, I am not confusing nurses with NPs. I am fully aware of the difference and in the clinic where I work (Indiana), the doctors do sign off on everything the NPs do and they do review each chart. I am not aware if this is a state law or just our best practices.

[Guest llerner]

Usually the plan states a copay for an office visit under the category of professional services which would include NPs, and nurses. There could be a higher copayment and usually some limitation on physical therapy, chiropractic etc.

Here is California, Kaiser and the other HMO do not distinguish between NP, MD and RN as far as office visits are concerned. If it is a capitated HMO, it would not matter what services for standard office visits are utilized by the member. In the future to reduce costs there very well could be variable copays based on doctor's time cost vs. NP/BSN/RN time. Even if the doctor has to review, it is a different matter to supervise than actually spend time with the patient.

[GBurns]

The question is not regarding co-pays which are made by the employees, it is about the reimbursements made by insurance companies, claims administrators etc to the service providers.