Leading nurse practitioners through the reimbursement maze/legal haze

5 tips for nurse practitioners on how to get paid and not get sued, from Carolyn Buppert, nurse practitioner and attorney

  1. Understand and apply Medicare's rules for billing physician services provided by nurse practitioners. For example, when a nurse practitioner performs a physician service, it may be billed to Medicare under the nurse practitioner's name and provider number or, if "incident-to" or "shared billing" rules are followed, under the employer physician's name and number. A failure to follow the rules could lead to a charge of fraudulent billing.

    For details, see these resources:

    Safe, smart billing and coding for evaluation and management

    Billing physician services provided by nurse practitioners in specialists' offices, hospitals, nursing homes, homes and hospice

    The primary care provider's guide to compensation and quality

  2. Learn how to negotiate decent terms of employment. The principles are
    • Know what you want, and be able to articulate it.
    • Describe what you have to offer, including the amount of revenue you can generate.
    • Learn what the other party wants.
    • Be able to articulate why what you have to offer fits with what the employer wants.
    • Put it in writing.

    For details, see these resources:

    Negotiating terms of employment: For nurse practitioners

    Template employment contract

    The nurse practitioner's business practice and legal guide

    Productivity plans for nurse practitioners: How and why

  3. Know the complaints and conditions that are red flags for malpractice. The top 3 are:
    • Breast lump, nipple discharge, breast rash or enlarged lymph node in supraclavicular or axillary area
    • Chest pain in an adult
    • Lower abdominal pain
    Rule out the worst thing first.

    For more recommendations on how to avoid malpractice, see these resources:

    Avoiding malpractice: 20 cases, 10 rules, five systems

    Prescribing: Preventing legal pitfalls

  4. Understand the reimbursement system for your practice setting. For example, hospice agencies may get reimbursement for nurse practitioner services from Medicare Part A and Medicare Part B. In order for a hospice to be reimbursed under Part B for physician services provided by a nurse practitioner employed by the hospice, the following statements must be true:
    • the patient is enrolled in hospice and
    • the patient has designated the nurse practitioner as attending physician.

    For more details, see these resources:

    Billing physician services provided by nurse practitioners in specialists' offices, hospitals, nursing homes, homes and hospice

  5. With every prescription you write, go through a SCRIPT analysis (Side effects; Contraindications; Right medication, dose, frequency, and route; Interactions; Precautions; Transmittal). Why? Because here are 9 common prescribing errors, with examples:
    • Clinician failed to explain possible side effects. Patient took Soma and Esgic Plus as prescribed, drove, and got into an automobile accident.
    • Clinician failed to take a complete patient history, and prescribed indomethacin in a patient with worsening kidney disease.
    • Clinician miscalculated the dose. Clinician calculated a Digoxin dose based on actual body weight. (Digoxin dose should be calculated based on ideal body weight.)
    • Clinician prescribed the wrong dose form. Clinician prescribed Cardizem CD TID. Cardizem is QID, Cardizem CD is QD.
    • Clinician specified wrong dosage frequency. Clinician ordered Gentamicin TID instead of Q8 hours.
    • Clinician overlooked drug interactions. Clinician wrote Rx for Erythromycin for patient on theophylline.
    • Clinician failed to adjust doses for renal dysfunction. Clinician ordered Impenemdilastatin: 1g q 6h (appropriate for patients with normal renal function) instead of 250 mg q 6h or less for a patient with renal dysfunction.
    • Clinician failed to write clearly. Pharmacist misread the Rx and dispensed the wrong medication.
    • Clinician failed to enunciate clearly when calling in prescription. Pharmacist dispensed the wrong medication.

    For more recommendations, see these resources:

    Prescribing: Preventing legal pitfalls

    Avoiding malpractice: 20 cases, 10 rules, 5 systems


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