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Reimbursement Issues and Realities
Because much of the funding for hospitals and much of the reimbursement for office practice comes from
Medicare, federal statutes and regulations and policies from the Center for Medicare and Medicaid
Services (CMS) have great impact on the interest of hospitals and medical practices in having NP
providers. For example, the Social Security Act, which governs Medicare and Medicaid, was written in
1965, before there were NPs. The Act frequently uses the word “physician” as if there were no other
healthcare provider. Other healthcare providers have had to get acts of Congress to be included in the
laws governing Medicare. The Act has been amended many times since the 1960s, but some relevant
portions of the Act remain that give permission to physicians and only physicians to provide care. NPs
made progress in 1997 when an act of Congress authorized NPs to be reimbursed directly for the care of
Medicare patients (Buppert).
1. Research the reimbursement realities in your state.
2. What is required to get reimbursed by Medicare, Medicaid and private Insurances.
3. How do you apply for provider status?
Page 5
Marketing, Negotiating and Developing APN roles
1. Research the requirements for an independent APN practice in your state
2. Discuss what should be included in a contract that you negotiate for a APN position.
3. Note if your state requires a collaborative or supervisory physician and what type of agreement
would be required in these cases.
4. Review the circumstances when a collaborative agreement would be required.
5. Discuss what should be included in a collaborative agreement in your state (many times defined by
your state statutes).
Page 6
Lifelong learning and the APN
1. Discuss the importance of lifelong learning for the APN. (This may be required for negotiations for
continue education monies and time).
2. Discuss important ethical issues that you anticipate to be a part of your APN practice.
3. Reflect on how you will apply Research to the health delivery system you will be working within and
your APN practice.
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