Can I Set Up an Independent Practice Providing House Calls?

Carolyn Buppert, NP, JD

Disclosures

August 14, 2000

Question

What are the implications of setting up an independent practice to provide house calls? What address do I put on the prescription pads?

Judy Celik, FNP

Response from Carolyn Buppert, NP, JD

An NP who wants to set up a house call practice should conduct the following analysis:

Response from Carolyn Buppert, NP, JD

If medical, then the NP would seek third-party payment under the appropriate medical CPT (Current Procedural Terminology) codes. Medicare will pay NPs for home visits, under the following conditions:

  1. The procedures billed conform with the requirements stated in the CPT manual.

  2. There is an applicable diagnosis, identifiable with an ICD-9 code (International Classification of Diseases, 9th Edition).

  3. The visit is medically necessary.

  4. The NP's documentation conforms with the Health Care Financing Administration's documentation guidelines.

  5. The NP is a Medicare provider.

  6. The NP follows the general rules for filing claims under Medicare.

Medicaid likewise will pay NPs for home visits, if the NP is a Medicaid provider and conforms with Medicaid billing requirements. Commercial insurers may or may not pay NPs for home visits. An NP starting a practice should determine which commercial payers are prevalent in his or her geographic area and query each insurer about 1) coverage of home visits, 2) reimbursement of NPs for home visits, and 3) procedures for obtaining reimbursement.

If the visits are primarily of a nursing nature, an NP will have to become a provider of home care services. States may require the providers of home nursing services to 1) get a certificate of need and 2) get a license. Medicare requires a physician's order for in-home nursing services and periodic recertification that the services are necessary. Presently, an NP cannot order nursing services in-home, no matter whether the NP is performing the nursing services or whether a separate home care company is performing the services. Commercial insurers may have rules that differ from Medicare. Commercial insurers may or may not pay for nursing services provided in the home.

If the NP plans to perform both medical and nursing services, the NP may have to meet the requirements stated in both of the paragraphs above.

Response from Carolyn Buppert, NP, JD

If the NP is to be paid by the patient, reimbursement is much simpler. However, patients who have insurance will not likely want to pay the NP out of pocket. Those who don't have insurance may not be able to pay the NP out of pocket. And, if the NP business owner is enrolled as a Medicare provider, the NP cannot charge a patient covered by Medicare directly, but must go through the billing process with Medicare and must accept the payment Medicare offers.

If the patient is insured, does the insurance cover the service the NP plans to provide?

Are the services within the state's legal defined scope of practice for NPs?

State nursing board information can be obtained at: National Council of State Boards of Nursing, http://www.ncsbn.org/files/boards/boardswebsites.asp

Response from Carolyn Buppert, NP, JD

Does the NP have the ability to admit a patient whom the NP finds in need of hospital, hospice, or nursing home care?

Response from Carolyn Buppert, NP, JD

  1. How will you get clients?

  2. Are there other providers in your area offering the same service?

  3. Which business structure (eg, sole proprietor, partnership, etc) is best for you?

  4. Do you have a referral network of social workers, physical therapists, and in-home aides?

As with any new business, it is wise to go through the steps of writing a business plan. A business plan for a nursing business is described in The Nurse Practitioner's Business Practice and Legal Guide.[1]

Regarding the address to print on the prescription pad, the NP will need a business address and business telephone number. There are several inexpensive ways to obtain each of these.[2]

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