NPs Seeing New Problems

Question: Our practice recently hired a nurse practitioner. Some insurance plans will not credential NPs; they allow NPs to perform only “incident-to” care (i.e., no new problems, only follow-up care of existing problems). This has resulted in under-utilization of our NP, as she is not allowed to see patients for straightforward, acute-care issues such as sinusitis or pharyngitis, as these are “new problems.”

Other practices have told us that their NPs do see these new problems. They just submit the bill under one of the physician’s names. Is this allowed? Can you help clarify this issue? We’d like our NP to be able to see these simple acute-care visits, which are well within her scope of training and are one of the main reasons we hired her.

Answer: The only national guidelines on this issue are those from Medicare.

For Medicare, you have two choices:

• Get the NP credentialed so she can bill directly for any patient, so long as she is practicing within her scope.

• Bill incident-to, where care delivered has to follow an initial course of treatment set by the physician.

If your commercial payers won’t credential NPs, I’d first of all start banging some drums about that. Make sure you have the right answer. Point out that the NP improves access and controls costs.

If other practices are billing as you describe, they perhaps know about some particularly odd payer policy. Ask these practices for documentation that shows it’s OK.

Commercial payers all have their own rules, but this doesn’t seem right to me.