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?
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.
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.
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
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!
what insurance panels accept NPs
I am a family NP and have been working in psychiatry for the past 6 years. My employer has just informed me that Blue Cross is no longer reimbursing care given by FNPs practicing in psychiatry. Is that true?
I’ve certainly heard of rumblings, however, this will vary from state to state and payer to payer. Depending on your state, you may be considered working out of your scope as an FNP being in psych.
Good morning! I live in Texas and was wondering about reimbursement. My twin and I own our own Family Practice, and have about 350 patients and still growing but it seems as if we are not getting far with reimbursement and payments. We are awaiting for the practice to start kicking back the funds to pay for the business but it seems we are still running short when it comes to reimbursement. Does it make a difference that we are not in a Full Practice Authority, and could this be why we are not seeing the financial reimbursements in full?
FPA should not affect reimbursements. Things to look at would be are you billing correctly? Are you getting denials and why? What is your AR like and who is paying attention to it? What is your fee schedule? Are you doing the billing yourself, or do you have a biller? If you have a biller, are they billing correctly and on time?
I would like to work for a company who will be doing the billing and credentialing for myself as a psychiatric nurse practitioner. Can you tell me what would be a fair percentage of my visits to offer them?
If I understand your question, you want to know the average cost of doing business with a billing company. This will vary a good amount but I’ve seen rates starting as low as 5% of revenue to 10+%. Shop around and definitely do your due diligence. Many of the companies on the lower end outsource and you may not have the control or ability to communicate with them as well.