Medicare reimbursement is a process whereby a doctor or any health facility is given funds for the medical services provided to a specific Medicare beneficiary. Individuals who possess medical coverage do not necessarily pay upfront for the services provided. The reimbursement process adopts cost-sharing payments in the form of co-insurance and deductibles (DesRoches et al., 2017). After agreeing on the Medicare reimbursement rates, Congress passed the motion in 1997, and it immediately became a law after the signing of the president (Huang et al., 2020). However, the laws became effective on January 1, 1998, following the Balanced Budget Act agreement (Huang et al., 2020). Nurse practitioners (NPs) spend more time with patients than medical doctors (MDs) or physicians, and they provide education and counseling services to the patients. The NPs can as well prescribe certain medications and treat some diseases. However, medical reimbursement for them is 85%, and that of medical doctors is 100% even when they provide almost the same medical services. Therefore, to create an effective health system, medical doctors’ and nurse practitioners’ medical reimbursement rates should be homogenized.
The work of NPs is well-known and widely appreciated by many bodies and patients. However, MDs provide essential information that is critical to their area of specialization. NPs are currently being reimbursed at a much lower rate of 80%, which is 85% of the practitioners’ schedule fee number (Razavi et al., 2021). The current COVID pandemic has proved that NPs and MDs should be treated the same for Medicare Reimbursement. Therefore, NPs should be reimbursed at the same rate as the MDs since they provide more support to the patients than the MDs.
Several bodies are attached to the Medicare Reimbursement scheme and are responsible for making significant NPs and MDs reimbursement decisions. Such bodies include government legislation acting in the Balanced Budget Act, insurance companies that act as third parties for approving Medicare funds to respective Medicare providers, and the state where the NPs and MDs provide services (DesRoches et al., 2017). Consequently, reimbursement rates differ from one state to another due to different medical plans endorsed by each state. Medicaid in Alaska is reimbursed at the rate of 124% compared to Medicare, while in California, 51% of the Medicare reimbursement is made (Huang et al. 2020). From the current laws, MDs can bill out the funds which the NPs have worked for, and this usually creates a conflict between the MDs and the NPs. Therefore, it is crucial to revise the laws governing the NPs and MDs’ reimbursement.
The first step to solving this discrepancy between NPs and MDs is by involving the political organizations and advocating for policy change. In 2012, the proposed motion of making equal reimbursement among the NPs and MDs failed to pass because of the anticipated drop of primary care rates by the insurance companies rather than raising the actual rate for the NPs (Razavi et al., 2021). Moreover, each NP’s responsibilities should be explicitly involved on the policy level to initiate change, which can be successful if the American Association of Nurse Practitioners (AANP) is included in policymaking (Razavi et al., 2021). However, while making changes, critical opponents such as insurance companies and practitioners should be kept in mind to prevent resistance, which might, otherwise, jeopardize the current efforts to make the health system efficient.
Advanced practitioners (AP) have been pushing for health care reforms that will enable effective medical services provision. The AP has been advocating for accessible health insurance coverage, and they are continuously fighting for easy access to primary services. Furthermore, the APs are continuously educating the nursing public on how some reforms can change people’s lives. Therefore, equal pay among the essential health worker such as NPs and MDs should be handled with care to ensure equal pay for equal work.
DesRoches, C. M., Clarke, S., Perloff, J., O’Reilly-Jacob, M., & Buerhaus, P. (2017). The quality of primary care provided by nurse practitioners to vulnerable Medicare beneficiaries. Nursing Outlook, 65(6), 679-688. Web.
Huang, N., Raji, M., Lin, Y. L., Chou, L. N., & Kuo, Y. F. (2020). Nurse Practitioner involvement in Medicare accountable care organizations: Association with quality of care. American Journal of Medical Quality. Web.
Razavi, M., O’Reilly-Jacob, M., Perloff, J., & Buerhaus, P. (2021). Drivers of cost differences between Nurse Practitioner and Physician attributed Medicare beneficiaries. Medical Care, 59(2), 177-184. Web.