Centers for Medicare and Medicaid Services and Reimbursement

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  • Topic: Centers for Medicare and Medicaid Services, Medicare and Medicaid, Registered nurse
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  • Published : February 17, 2013
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Is national certification important with respect to billing and reimbursement? When? Discuss reimbursement barriers and issues that hinder or prevent APNs from receiving reimbursement for services rendered. What are steps APNs must take to increase the likelihood for reimbursement?

Qiuyue Li
Asuza Pacific University
Karen D French
02/12/13

1. The Question
I believe national certification is important with respect to billing and reimbursement. National certification is often required in order to acquire proper credentials. For example, certification is now required to acquire a credential from Medicare, Medicaid, and the Department of Veteran Affairs. Health insurance companies also require certification for credentialing. APNs who are Medicare providers must be a participating provider, which means they will “accept assignment;” the allowable charge determined by Medicare. As of May 2007, APNs need the following qualifications to be a Medicare Provider: a state registered nurse (RN) and advanced practice registered nurse (APRN) license, national certification in an advanced nursing specialty, a master’s degree in nursing, and a national provider identifier (NPI) number. Clearly, APNs should be paid for services rendered for health care whether they work independently, share a joint practice with a physician colleague, or are employed with an institution or provider network. However, there are some barriers and issues that prevent APNs from receiving reimbursement. To increase the likelihood for reimbursement, our APNs must unite , consolidate, and take some measures. I would like to discuss some issues and steps APNs must take regarding reimbursement as followed. First, why do APNs not receive equal reimbursement? The Medicare Payment Advisory Commission examined the payment differentials between the clinicians and physicians. Since the nature of billing codes is imprecise, the Center for Medicare and Medicaid Services was not able to distinguish the...
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