Solved by verified expert:GOOD AFTERNOON,I AM NEEDING ASSISTANCE WITH A RESEARCH PAPER. IT MUST BE IN APA FORMAT, AND USE THE RESOURCES I HAVE ATTACHED TO THE DOCUMENT. IT IS A GRADUATE SCHOOL ASSIGNMENT. IF YOU HAVE ANY QUESTIONS PLEASE REACH OUT TO ME I WILL BE HAPPY TO ELABORATE MORE. the topic is based on nurse practitioners and medicare reinburmsments.
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THISI IS THE TITLE:
MEDICARE DOCUMENTATION GUIDELINES AS
THEY RELATE TO QUALITY & COST IN
HEALTH CARE & THE NP ROLE
Medicare has 4 programs (NASI, n.d):
o Part A – Hospital Insurance
o Part B – Voluntary program for healthcare bills such as doctors and outpatient
o Part C – Medicare Advantage (MA)
o Part D – Prescription Drugs Benefits
PLESE IN THIS AREA EXPALIN EACH PARTS, BUT ALSO EXPLAIN HOW IT IS
APLLICABLE TO A FAMILY NURSE PRACTITIONER WHICH MEDICARE OPTION IS
APPLICABLE TO A FAMILY NURSE PRACTITIONER.
Quality of care is basically the extent to which the available health services enable patients
achieve the desired health outcomes (Lohr & Schroeder, 1990).
• Medicare is one of the federal programs aimed at providing quality care to specific
American groups (above 65 years and those with disabilities).
• It was created in 1965 (NASI,n.d).
• This program has ultimately increased life’s longevity more so for older citizens.
DESCRIPTION OF THE ISSUE BACKGROUND:
Medicare Billing Option #1: Direct Billing:
o Nurse practitioners may direct bill under their NPI and receive-direct payment
o Reimbursement for services provided by PAs and NPs are reimbursed at 85% of
the physician fee schedule.
▪ Payment is made directly to the NP for assistant-at-surgery services at
85% of 16% of the amount a physician is paid under the Medicare ( CMS,
▪ Payment for services furnished incident to the services of a NP in a setting
outside of a hospital is made to the NP at 85% of the amount a physician is
paid under the Medicare
Medicare Billing Option #2 Incident to “Billing”:
▪ The “Incident to” is a Medicare phrase, meaning services furnished as an
integral, part of the physician’s professional services in the course of
diagnosis or treatment of an injury or illness.
▪ In order to qualify for incident billing, the services being provided must be
under the direct personal supervision. The “Nonphysician”must be
employed of the ordering physician/physician group, leased employee, or
independent contractor of the physician/physician group.
SLIDE: DESCRIPTION OF THE ISSUE CURRENT STATUS
• Nurse practitioners are independently licensed providers that practice in both primary and
acute care. Nurse practitioners have demonstrated the ability to provide high-quality health
care and incur the same overhead costs as physicians who provide care to patients.
• Currently, “Under current payment models, Medicare reimbursement, state
Medicaid programs, and third-party payers, nurse practitioners are reimbursed only
about 85 percent of the rate paid to physicians for providing the same services.
• These have a negative effect on health quality as these contractors only process
claims without evaluating healthcare service effectiveness (Tunis et al., 2011).
• The nurse practitioner outcome data are almost always obscured because their
services are hidden under the higher-paid physicians’ provider numbers, so a private
practice or hospital can collect the maximum payment.
SLIDE: DESCRIPTION OF THE ISSUE CURRENT POLICY
Currently, most decisions to do with coverage have been deferred to contractors in
the region whose role is claim processing (Tunis et al., 2011). Services are
o Capitated Medicare
o Fee for service Medicare
• CMS does not take action regarding the coverage for services with no added
value whatsoever in comparison to the less expensive options (Tunis et al., 2011).
• As such, the current policy doesn’t significantly reduce cost of care. It also fails to
improve quality and general health outcomes.
SLIDE: DESCRIPTION OF THE ISSUE LOCAL–> TEXAS IS LOCAL AREA
The Board of Nursing is authorized by the NPA to regulate APRNs who are licensed in
one or more of the following recognized role.
The Advance practice registers nurses are recognized and may contract as Primary care
providers in managed-care organizations.
Under certain circumstances, physicians in the Texas Medicaid Program may bill for an
Advance practice register nurse services and receive one hundred percent of the physician
o Some programs, such as Texas Health Steps, reimburse all providers at the same
The Advance practice register nurses are listed in the Texas Insurance Code as
practitioners who must be reimbursed by reimbursement from the health insurance plans.
All HMOs and PPOs in Texas must list an APRN on provider panels if the APRN’s
collaborating physician is on the panel and the physician requests that the APRN also be
DESCRIPTION OF THE ISSUE STATE OR FEDERAL AGENCIES THAT
REGULATE OR ENFORCE PRACTICE
Legislation uses Tuses the provider-neutral term “healthcare provider,” inclusive of
APRNs as providers for whom the plan must provide reimbursement
With much statistical evidence of safe care and equal outcomes provided by nurse
practitioners, the state regulation of NP practice varies significantly, limiting NP’s
abilities to meet the growing healthcare needs of the nation.
SLIDE:ANALYSIS OF THE ISSUE EFFECT ON THE NP ROLE:
• The state licensure regulates NP practice and is a barrier to NPs practicing to the fullest extent of their
education and training.
• The emergence of Stark Acts have made the NP – patient relationship more complex especially where
financial obligations come to play regarding health facility ownership.
• The IOM report (2011) has recognized that restrictive scope-of-practice regulations of nurse
practitioners in some states as one of the most severe barriers to accessing care for patients.
• A nurse practitioner with the same educational preparation and national certification may face a
compendium of restrictions when relocating from one state to another, thus limiting their scope of practice
• The American Medical Association, believe that because physicians have more extensive and more
rigorous training than Nurse Practitioners that Nurse practitioners are incapable of providing quality, safe
care at the same level as physicians (American Medical Association (AMA), 2010; Fairman, Rowe,
Hassmiller, & Shalala, 2011).
THESE ARE THE TOPCIS I NEED
TO ADRESS IN APA FORMAT:
Description of the issue Background
Description of the issue Current status
Description of the issue Current policy
Description of the Issue local
Description of the issue State or federal
agencies that regulate or enforce
Analysis of the issue Effect on the NP
Analysis of the issue Health care
Poghosyan, L. (2018). Health Policy and Politics: Federal, State, and Organizational Barriers
Affecting Nurse Practitioner Workforce and Practice. Vol. 36/No.1.
Hain, D. Fleck, L. (2014). Barriers to nurse practitioner practice that impact healthcare redesign.
OJIN: The Online Journal of Issues in Nursing Vol. 19, No. 2, Manuscript 2.
Blaschka, C., Rath, D., & Tetens, J. (2019). Abstract. Reproduction in Domestic Animals, 54(S1), 3.
Center for medicare advocacy issues statement on quality of care. (2018, Sep 7,). Targeted News Service
Retrieved from https://search.proquest.com/docview/2101246477
Multistate Reimbursement Alliance (MSRA). (n.d.). Retrieved from
Nurse Practitioner Reimbursement Gap Remains Among Public, Third-Party Health Insurance Payers.
(n.d.). Retrieved from https://www.napnap.org/nurse-practitioner-reimbursement-gap-remains-amongpublic-third-party-health-insurance-payers
Position statement on reimbursement for nurse practitioner services. (2016). Journal of Pediatric Health
Care, 30(3), A18. doi:10.1016/j.pedhc.2016.01.008
Target Audience: Medicare Fee-For-Service (FFS) Program (also known as Original Medicare). (2016).
Complying with medical record documentation requirements
USES THESE RESOURCES THANK YOU
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