Case Study 2
Advanced practice registered nurses (APRNs) must consistently demonstrate expertise in clinical skills while balancing an expertise in navigating the third-party payer rules in an uncertain, ever-changing health-care landscape. APRNs have demonstrated the ability to administer high-quality health-care services in a variety of settings with the cost of care significantly less than that of internal medicine and specialty physicians. Whether providing services under the direct supervision of a physician or through a collaborative agreement, the successful APRN must not only understand the clinical skills required to provide care, but also that the cost of providing that care affects the provider as well as the patient.
1. What are the general categories of third-party payers? What do they have in common?
2. It is recommended that patient responsibility payments be collected before services are rendered. Why is this important?
3. What should you understand before entering into a contractual or employee–employer relationship with an “opting-out” physician?
4. What are the differences between The Merit-based Incentive Payment System (MIPS) and The Advanced Alternative Payment Model (Advanced APM)?
5. Patients receiving primary care from the physician and “non-physician” (i.e., NPs) may submit billing either directly under the NP’s National Provider Identifier (NPI) or under the physicians’ NPI as “Incident to a physician’s professional service”. If a patient is seen by a NP, what conditions must be met in order for the billing to be submitted under the physician’s NPI?