Tuesday July 23rd 2019

Wave of newly insured individuals escalates the need for services and payment

Lisa Summers

Significant barriers exist to advanced practice registered nurses (APRNs) getting paid by private insurers. The problems are varied and include refusal to credential APRNs at all, creating requirements for supervision that exceed state requirements, and inequitable reimbursement.

While reimbursement has been a long-standing barrier to APRN practice, the need to effectively address the problem has become critical as new state insurance exchanges have been launched and a growing number of Americans have gained health insurance coverage. The Institute of Medicine’s Future of Nursing report highlighted this problem in a section entitled “Outdated policies of insurance companies” and has recommended: “Require third-party payers that participate in fee-for-service payment arrangements to provide direct reimbursement to APRNs who are practicing within their scope of practice under state law.”

The American Nurses Association (ANA) has been working with organizations representing the APRN roles, purchaser and consumer groups, and others to overcome this barrier. One of the challenges to developing an effective strategy, in addition to a rapidly changing industry, has been a lack of data on which insurers credentialed and reimbursed APRNs. The National Nursing Centers Consortium (NNCC), the organization that represents nurse-managed clinics, has conducted two national surveys documenting the disturbing fact that less than half of all managed care insurers in the United States recognize NPs as primary care providers.

Recently, the American College of Nurse-Midwives (ACNM) used the NNCC methodology to survey marketplace insurers regarding coverage of midwifery services. The ACNM identified 277 unique insurers, reached out to 232 of them, and completed a survey with 85. The full report, “Ensuring Access to High Value Providers,” can be found online at www.midwife.org.

Key findings about insurance plans include:

• 20 percent do not contract with CNMs, even though CNMs are licensed to practice in all 50 states and the District of Columbia.

• 17 percent do not cover primary care services offered by CNMs, even though ACNM standards defining the scope of practice for these providers include primary care services.

• 14 percent indicated they impose restrictions on CNM practice that conflict with their scope of practice under state laws and regulations.

• 24 percent will not cover CNM professional services provided in a birth center and 56 percent will not reimburse CNMs for home birth services.

• 50 percent do not pay CNMs the same amount paid to a physician when they perform and bill for the same service.

• 10 percent of plans that contract with CNMs do not list them in their provider directories, making them invisible to potential and current enrollees. Forty percent of plans listing CNMs in their provider directories list them under the obstetrician-gynecologist category, making it difficult for women searching for midwives to find them.

• 47 percent do not contract with birth centers to cover facility costs associated with births in that setting, despite studies showing very good outcomes and low costs associated with birth centers.

• 8 percent contracting with birth centers did not list them in their provider directory.

ANA is committed to using these findings to work with ACNM and our APRN partner organizations to ensure that third-party payers provide direct and equitable reimbursement to APRNs.

— Lisa Summers has recently returned to ANA as senior policy fellow, APRN Issues.

Resources

NNCC Managed Care Contracting Toolkit
www.nncc.us/site/index.php/consultation/tool-kit/section-a

Ensuring Access to High Value Providers: ACNM Survey of Marketplace Insurers Regarding Coverage of Midwifery Services
www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000004394/EnsuringAccesstoHighValueProviders.pdf

ANA resources

Finances & Reimbursement
www.nursingworld.org/EspeciallyForYou/AdvancedPracticeNurses/Finance-and-Reimbursement

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