Reimbursement and Insurance in Health Care

Introduction

Many important factors influence the quality of nursing practice and cooperation between patients and nurses. A number of financial aspects remain poorly explained to the participants, and the government, as well as professional organizations, is involved in the discussion of various issues. The American Nurses Association focuses on the development of specific reimbursement policies to ensure that Advanced Practice Registered Nurses (APRNs) receive their financial compensations for services from Medicaid and Medicare. Changes in these policies depend on the chosen insurance plans, payer types, and other insurance efforts like the value-based insurance design (VBID).

History of Reimbursement for APRNs

The main purpose of reimbursement policies in the US healthcare system is to develop a revenue stream. In 1966, Medicare was offered as a health insurance program to provide Americans with healthcare services, and reimbursement policies were introduced to control billing activities and compensate expenses and services at state and federal levels. In 1990, first changes were made to promote reimbursement for skilled nursing facilities in rural areas only. In 1997, the Balanced Budget Act was created to recognize primary care case managers and expand policies for APRNs and clinical specialists. At this moment, Medicare is responsible for paying 85% of the physician fee schedule (MedPAC Staff, 2019). This coverage is available to cover inpatient and outpatient services.

Reimbursement Impact and Changes in Nursing Practice

The impact of reimbursement has a number of positive outcomes. For example, in my nursing practice, this financial opportunity shows the possibility to increase the participation of APRNs in primary care. In addition, many nurses are able to provide patients of rural areas with services where the help of physician’s remains limited due to different reasons. Nursing practice undergoes multiple changes due to the unstable financial and economic situation in the country.

For example, one of the potential changes can be the elimination of “incident to” billing for services offered by APRNs (MedPAC Staff, 2019). This change provokes concerns about national provider identifiers and new sources of payment. However, the role of Medicare and its coverage of services are the same, so it would not influence the quality of services or the number of participants in care management. Nurses will be able to recognize their roles in practice and contribute to quality improvement instead of thinking about the financial aspects of their practice.

Payer Types and Insurance Plans

Patients and nurses may be poorly aware of the peculiarities of insurance plans and payer types, but these issues influence the quality of care and access to resources. There are three types of insurance players in the US healthcare system to pay for services directly to providers. They include government organizations (Medicare or Medicaid), commercial (United Healthcare), and private (private insurance companies). These payers offer different insurance plans, and the most common are indemnity (to reimburse offered services), health maintenance organization (to use one provider), and point of service (to use out-of-network services with cost sharing). These participants and steps can easily provide revenues for my nursing practice.

VBID

To promote positive clinical outcomes and decrease costs, VBID can be used. Its goal is to increase the quality of healthcare services by structuring cost-sharing elements and analyzing financial incentives. Many organizations and other public entities apply this model in their health plans. For example, cost sharing can be implemented for a particular area of services like preventive care or emergency services. Although other services may be discouraged, clinical outcomes in the chosen fields will be improved.

Conclusion

In general, financial aspects of health care introduce a complex theme for discussion. Despite the intentions to be served in the best way, patients know little about who should pay for medical help or how nurses receive their salaries. At the same time, it is impossible for APRNs to offer their services free, and the importance of insurance plans must be underlined. In the United States, there are several payer types, plans, and designs, and healthcare facilities cooperate with the government to established appropriate environments for patients and employees.

Reference

MedPAC Staff. (2019). Improving Medicare’s payment policies for advanced practice registered nurses and physician assistants. MedPAC. Web.