Nurse Practitioners and Insurance Reimbursement

Insurance Reimbursement for Nurse Practitioners

Medscape  recently posted the results of a survey where physicians rated insurance companies in terms of best and worse to work with and the factors that lead into those ratings.

This got me to thinking about us. Insurance reimbursement for NPs and other Advanced Practice Nurses is all over the board. Some companies recognize Nurse Practitioners and reimburse them for the work they do, other companies seem to be ignorant of the work we do. Then it also varies by state and region.

For example, here in Washington State, for the most part, I don’t have difficulty with insurance reimbursement. I am credentialed with the two “Blues” in our state, yet I hear from NPs in another state where the “Blues” refuse to credential NPs. Does not make sense does it.

If you have having difficulty, contact the American Academy of Nurse Practitioners and get in touch with the Multi-State Reimbursement Alliance people for your region.
OK. Let’s hear from you. What state are you in? Who is credentialing and who is not? What have you found that works and what doesn’t. Advice for others in your area about insurance reimbursement?

Comments 4

  1. I have been credentialed with NJ Horizon Blue Cross/Blue Shield for the past 15 years. I opened my own dermatology practice. Supposedly, I am credentialed with them but I am must meet criteria for certain plans. They did not specify what the criteria is and stated they do reviews periodically. The last review was in 2013. I have patients that have followed me and would like me to be their provider and I cannot wait years for a review. They did say one should be coming up. How can requirements be so vague. Is there a way to know exactly what plans cover me and the rate. I know Medicare reimburses at 85% but is that true for other commercial plans?
    Please advise how I should move forward with different insurance plans for optimal and fair coverage.

  2. Post
    Author

    Maria,

    Each third party payer is different in terms of what they will offer in their contracts. Your best bet would be to work with your provider rep. That person can tell you about reimbursement rates based on your contract and the CPT codes in question.

  3. I’m currently in the process of opening an independent nurse practitioner practice in Illinois. Its been very difficult to determine the actual reimbursement rates for various services. Please point in the right direction

  4. Post
    Author

    Hi William,

    Reimbursements from government plans (Medicare, Medicaid, Worker’s Comp, Tricare, VA etc) are public information and as such you can look them up online by visiting their respective websites.

    On the other hand, commercial plans are proprietary and they do not readily share that information. Call their provider reps and talk with them. Ask them for average reimbursements for NPs in your area for specific codes. They will often give you a few of them. Use the CPT codes that would be common for your practice. My experience has been about 5 or 6 codes max. Now if you are already credentialed, even under someone else, they likely will be more forthcoming.

    Thanks for your question and good luck on your new practice!

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