How Do I Bill Commercial Insurers for Palliative Care Consultations?

Carolyn Buppert, NP, JD

Disclosures

June 05, 2003

Question

What is the best method for a nurse practitioner (NP) to bill commercial insurers for palliative care consultations? Does the NP need an individual contract or must they bill under a physician? What if the collaborating physician has a contract with the insurer through a separate physician billing entity, which the NP is not affiliated with?

Response From Expert

Carolyn Buppert, CRNP, JD
Nurse practitioner and attorney who specializes in the legal issues affecting medical practices and nurse practitioners. She is the author of 5 books. Ms. Buppert counsels clients, and lectures extensively on reimbursement issues, how to avoid malpractice, and contract negotiation. She is also president of Better Life Health Care Systems, which contracts with businesses and educational institutions for nurse practitioner services. Through that company she serves as Director of Student Health at St. John's College in Annapolis, Maryland. Her Web site is www.buppert.com

 

The answers to these questions will depend upon the policies of the commercial insurers involved. These policies vary greatly.

Before billing a commercial insurer, follow these steps:

 

  1. Make sure you meet any qualifications that the commercial insurer requires. In order to do this, you have to find out each insurer's policies regarding reimbursing nurse practitioners (NPs) and reimbursing for consultations for palliative care. Commercial insurers can make their own policies regarding covered services and the classes of clinicians who may be reimbursed. For example, one commercial insurer might pay a physician for consultations performed by an NP, but require that everything be billed under the physician's name. Another might pay NPs under the NP's name. Another might insist that a medical doctor perform a consultation in a specific specialty. Some insurers pay NPs at the same rate as medical doctors; some pay a reduced rate when a service is provided by an NP.

  2. Ascertain that the patient is not enrolled in hospice. If the patient is in hospice, then the Federal and state regulations regarding hospice apply, and, in most cases, hospice becomes the medical care provider.

  3. Be prepared to provide the insurer with evidence that you are qualified by special education, training, or experience to provide a consultation.

  4. Be prepared to supply the insurer with the state law that gives you the legal authority to provide consultations. If state law says nothing about consultations being within your scope of practice, you should argue that state law gives you the authority to take a history, perform an examination, diagnose, plan and order treatments, and prescribe. These are the elements of a consultation.

  5. Be prepared to provide the payer with your progress note and/or the letter you sent the clinician who referred the patient for consultation. The letter to the referring clinician must explain your findings, your impressions, and your recommendations for the referring clinician in managing the patient.

  6. Bill an appropriate CPT (Current Procedural Terminology) code for the consultation. See the first 35 pages of Current Procedural Terminology for the codes related to the various settings.[1] The codes for an office or outpatient consultation are different from those of an inpatient consultation, for example. Learn the CPT requirements for history taking, examination, and medical decision-making for each level of consultation. On the claim form, enter an ICD-9 code for the symptom or condition about which you are consulting -- for example, abdominal pain, left lower quadrant (789.04), or nausea (787.02) -- and the underlying condition -- such as malignant neoplasm, colon (153.9).

Who your collaborator is may or may not be important to the third-party payer. It depends entirely upon the insurer's policies. For example, some commercial insurers want everything billed under the name of the practice owner. If a practice includes Dr. X (the owner), Dr. Y, Dr. Z, and NP A, whose collaborator is Dr. Y, some payers want everyone's bills submitted under Dr. X's name. Other insurers want to credential and track utilization on each clinician. Others don't credential anyone and don't track anything but dollars paid out.

In some states, a law requires certain classes of commercial insurers to reimburse medical services provided by an NP. In other states, there is no such law. (This information would be found in the insurance code for each state.)

It is frustrating for all clinicians when one insurer's policies differ from another, but that is the current situation. To get paid, a practice's staff needs to analyze each patient's insurance provisions, preferably before the services are provided. If the billing staff obtains the insurance information before the patient arrives, they can make the necessary inquiries to determine the payer's policies, and will have time to call the patient back, if necessary, and inform the patient that you cannot accept his or her insurance.

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