#nursepracticion – KR2 Medical Billing

According to Anthem BCBS (NY) starting for any DOS 11/1/24- the PA/NP will be updated to align with CMS guidelines.

Please note the following services will be eligible to be performed by the PAs/NPs and reimbursement reduction will apply:

– Preventative care services

-Radiology services

Services that are not going to be reimbursed separately:

-Drugs

-Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS)

-Laboratory Services and Laboratory Screening Services

Billing: PA/NP has to bill with their own TIN and NPI number.

For the full policy please click here:https://www.anthembluecross.com/provider/policies/reimbursement/

CMS payment for NP/PA services:

-NP services: 85% of Physician Fee for outside of hospital setting or SNF, or 80% of lesser billed charge

-NP services : incident to services done by auxiliary personnel outside hospital or SNF setting – 85% of Physician Fee Schedule

CMS link: https://www.cms.gov/medicare/payment/fee-schedules/physician-fee-schedule/advanced-practice-nonphysician-practitioners/advanced-practice-registered-nurses-aprns

-PA services: 85% of PFS- physician fee schedule.

CMS link: https://www.cms.gov/medicare/payment/fee-schedules/physician-fee-schedule/advanced-practice-nonphysician-practitioners/physician-assistants-pas

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This reimbursement policy update applies to AETNA Commercial Plans for Texas Medicare, Commercial and IVL exchange networks.

Recently, AETNA expanded their policy for midlevel reimbursement policy- that includes reimbursement at 75% of the negotiated fee or recognized charge for
covered services for the following mid level professionals:

audiologists, genetic counselors, massage therapists, nutritionists, respiratory therapists and registered dietitians

Effective 07/01/2022- AETNA will add reimbursement of 85% of physician market rate, unless otherwise contracted for (nurse practitioners, certified nurse midwives, physician assistants and clinical nurse specialists) regardless of contract, employment status or place of service (that is, office or facility).

Who and what is not affected?
• Mid-level providers with specific rates in their contract
• Certified registered nurse anesthetists and registered nurse first assistants
• Claims billed with an Assistant Surgery modifier
• Covered DME, orthotics, prosthetics, supplies, drugs, laboratory, radiology services
and immunizations billed by a mid-level practitioner
• Providers contracted through a third party or vendor

Does this change affect the precertification and concurrent management process?

No. Aetna® will continue to make utilization management decisions and send the
appropriate letters and other communications.

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Tag: #nursepracticion

Anthem BCBS (NY providers): PA/NP reimbursement

Aetna: Mid level practitioner reimbursement policy-07/01/2022

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