Lessons Learned From Nurse Practitioner Independent Practice

A Conversation With a Nurse Practitioner Entrepreneur

Joyce A. Hahn, PhD, RN, NEA-BC, FNAP; Wesley Cook, APRN, FNP-BC, CPSN


Nurs Econ. 2018;36(1):18-22. 

In This Article

Lesson 2: Know Who Each Insurer Will Directly Reimburse

Lack of access to direct reimbursement from some commercial payers is unsurprising but important to understand. Commercial payers are understandably entrenched in physician-controlled credentialing practices. Further complicating NP advancement with commercial payers is an historic lack of NP representation on advisory boards. It is imperative APRNs work with commercial payers to gain membership on advisory boards and credentialing panels. Without concerted effort to level the ground, physician-centered policies will continue to prevail, hampering NP-led care innovations.

Although CareFirst, a BlueCross BlueShield subsidiary, has been a pioneer in recognizing NPs as primary care providers and leaders in their Patient-Centered Medical Homes, not all commercial payers have followed suit because they do not understand the value of NP practice. The best resource for understanding provider status is each payer's policy manual. It is dense, provides a cure for insomnia, and will have you tearing your hair out if you try to read the entire thing. Use the "find" mechanism of your internet browser or PDF reader to your advantage. And, consult your attorney, who will know precisely who and what to query concerning APRN provider status policies. Also, consult your local NP professional organization. Members are often valuable assets, as are the leadership team's network of contacts.

Knowing which payers allow primary care provider status as well as any procedural prohibitions for NPs will be helpful when writing your business and marketing plans. Maintain a file of commercial payers, their stance on NP provider status, and their credentialing and recredentialing requirements. If your locality affords you full practice authority, lead the way for NP advancement by challenging the policy in writing with the assistance of your attorney.