ancillaryservices neurology, rheumatology, etc., is making it more difficult to find a satisfactory blend of NP/MD specialties. To prevent risk of a figurehead role and to support optimal-care provision, this quandary supports the need to promote respect for both the science of wound care and for those qualified healthcare professionals who currently demonstrate wound care expertise. Since both of these efforts remain ongoing, it is particularly important to the national goal of high-quality, costeffective healthcare delivery that the novice wound care NPs who must receive practice supervision choose an MD with a wound certification and significant wound care practice experience.
NP & HOPD Business Options
Much like the level of autonomy and supervisory structure that an NP practices within a given state will vary, the practice and business model for NPs in an HOPD includes three general options. 1. NP Employed by the Hospital If the NP is already a salaried employee of a hospital and is providing care to acute patients, the hospital is accounting for the cost of the NP on their acute care “cost report.” If the NP decides to move to the HOPD, he/she must be removed from the acute care cost report because, logically, his/her work can no longer be bundled into the costs of that setting. When the NP becomes a salaried, qualified healthcare professional in the HOPD, he/ she will transfer his/her NPI number to the hospital, which will use that number to bill for the NP’s work in the HOPD. NOTE: It is difficult, but not impossible, for the NP to retain inpatient and outpatient responsibilities as a salaried hospital employee. Careful attention must be paid to the risk of overlap between accounting for the NP in the acute care cost report and billing with the NP’s NPI number for services performed in the HOPD. In May 2012, CMS made the decision to support the right of hospitals to grant privileges to NPs.4 If this scenario evolves to practice, an NP could work as a hospital consultant, similar to how many of today’s physicians practice. The wound specialist NP could assist with
acute wound care delivery and could be removed from the hospital’s cost burden. This would lead to a more fluid NP practice environment, which could more easily include the traditional fee-for-service acute and post-acute (includes HOPD) settings as well as the accountable care organization environment. Some physicians have voiced concern that expansion of NP practice could negatively impact the finances of physician practices. However, recent analyses reported by the 2012 National Governor’s Association Paper “The Role of Nurse Practitioners in Meeting Increasing Demand of Primary Care” dispel this concern to be unsupported by fact.5 Physician income has not dropped in states that have granted increased NP autonomy due to complimentary MD/NP roles. Furthermore, these states have enjoyed an overall increase in thoroughness and quality of care delivered to their residents. 2. NP Within Physician Group If the NP is a salaried member of a physician group practice, he/she transfers his/her NPI number to that practice. When the NP provides independent service in the HOPD, the group practice submits claims to the insurance company via the NP’s NPI number and identifies that the services were provided in the HOPD. Typically, this arrangement will require a contractual practice agreement, which should include a practice protocol between the NP and a group physician. While working in a physician group, this author developed a generic wound treatment protocol that was kept on file at the practice site and in the HOPD. 3. NP With Independent Practice Within all states where NPs have the option to begin an independent practice, he/she must practice within state practice guidelines, many of which involve some level of physician collaboration including a protocol to define care guidelines. To practice in an HOPD, the NP must also be credentialed by the hospital system as an approved provider of care within the HOPD. Credentialing involves a review and approval of the provider’s credentials, capabilities, and practice structure. In the
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independent practice model, the NP bills under his/her assigned NPI number for wound care services provided in the HOPD. The key business consideration for the NP is to identify which insurances recognize NP practice and under which situations. For example, Medicare fee-for-service is very supportive of NP practice and reimburses the NP 85% of Medicare’s physician fee scale. However, some Medicare HMOs or Medicare Advantage plans do not reimburse NPs. For dually eligible (Medicare and Medicaid) patients, supplemental Medicaid programs generally reimburse NPs the remaining 20% of the Medicare allowable. Beware: not all state-sponsored Medicaid programs allow NP participation. Many private insurance companies will only reimburse an NP who is contracted with a credentialed physician, while others continue to refuse to recognize any level of reimbursement for an NP in independent practice. As our population ages and chronic wounds prevalence increases, HOPDs will continue to be seen as valuable resources. Refer to Table 1, a checklist that NPs should consider, and Table 2, a checklist that HOPDs should consider, for ensuring optimal NP placement. n Jennifer Hurlow owns her own NP practice: Wound Practitioner LLC, Germantown, TN. She may be reached at jenny.hurlow@gmail.com. References 1. Hooker R, et al. Does the employment of physician assistants and nurse practitioners increase liability? Journal of Medical Licensure and Discipline. 2009;95(2):6-16. 2. State practice environment. American Association of Nurse Practitioners. Accessed online: www.aanp.org/legislation-regulation/ state-practice-environment. 3. Nurse practitioner prescribing authority and physician supervision requirements for diagnosis and treatment, 2011. Kaiser State Health Facts. Accessed online: www.statehealthfacts.org/comparemaptable. jsp?ind=890&cat=8. 4. Turner S. CMS broadens concept of hospital ‘medical staff ’ to provide greater opportunities for nurses and other nonphysician practitioners. Geriatric Nursing. 2012;33(4):302-3. 5. The role of nurse practitioners in meeting increasing demand for primary care. NGA Center for Best Practices. Accessed online: www.nga.org/cms/center. Today’s Wound Clinic® May 2013
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