Insurers' Contracting Policies on Nurse Practitioners as Primary Care Providers

Abstract

A national survey showed that nearly half of all major managed care organizations in the United States refuse to credential nurse practitioners as primary care providers. In nurse-managed health centers throughout the country, nurse practitioners provide primary care to underserved populations with similar outcomes to primary care physicians. Insurers' prohibitive credentialing and reimbursement policies reduce these centers' capacity for growth and, in turn, threaten the long-term sustainability of a key component of the health care safety net. Two years after conducting a national survey of insurers' credentialing and reimbursement policies regarding primary care nurse practitioners, researchers returned to the subject matter and found that many of the same financial barriers to nurse-managed health center sustainability still exist. Although some progress had been made since 2005, this progress did not appear to be attributable to regulatory changes or renewed enforcement of existing laws.

Decreasing barriers for nurse practitioner social entrepreneurship

“…Nurse‐managed clinics continue to depend on private‐pay patients, third‐party reimbursement, Medicaid and Medicare reimbursement, private grants, and government funding (Hansen‐Turton, Ritter, & Torgan, ; Wilson, Whitaker, & Whitford, ). The patient populations in rural clinics include the uninsured, the underinsured, or patients living in poverty (Hansen‐Turton et al., ). Patients who are unable to pay are often offered a sliding payment scale, based on their income, or a payment plan limiting income to the practice and threatening financial sustainability.…”

Revisiting Scope of Practice Facilitators and Barriers for Primary Care Nurse Practitioners

“…delivery of high-quality patient care (Hansen-Turton, Ritter, & Torgan, 2008;Pohl, Hanson, Newland, & Cronenwett, 2010). Some of the barriers include required supervision or collaboration with physicians for prescribing certain medications or certifying specific services (Pearson, 2012), and the inability to sign some forms for their patients such as workers' compensation forms or handicap parking permits (Barton Associates, 2012).…”

Are Managed Care Organizations in the United States Impeding the Delivery of Primary Care by Nurse Practitioners? A 2012 Update on Managed Care Organization Credentialing and Reimbursement Practices

“…This is similar to previous reports in the literature on the credentialing practices of MCOs. 9,10 Nonrespondents included 134 HMO representatives who declined to participate, and 103 HMOs where, after repeated contacts, the authors were unable to reach a representative who could describe credentialing and reimbursement practices.…”

“…Many managed care organizations (MCOs) have historically refused to credential NPs as primary care providers. Hansen-Turton and colleagues 9,10 reported MCO credentialing rates of 33% in 2005 and 53% in 2007. Moreover, among those MCOs that do credential NPs as primary care providers, many continue to reimburse NPs at a lower rate than primary care physicians for the delivery of this care.…”