United States: Reap The Benefits Of Nonphysician Providers (NPPs)

Nonphysician providers (NPPs) play a central role in the future of health care delivery in the United States. Medical practices are finding that nonphysican providers, also referred to as "NPPs," can extend the therapeutic reach of their physicians with the added benefits of increased patient satisfaction and improved net profits. However, there are issues you should consider before proceeding.

Find the Right Person

There are two primary categories of NPPs:  Physician assistants and nurse practitioners. Which category is best for your practice depends on which is licensed in your state and the range of activities that the NPP in question is licensed to perform.

An NPP may be able to function independently or work under a doctor's supervision — again, depending on relevant state law. Typical services that an NPP of either type may provide include:

  • Coordinating health education, patient counseling and patient care;
  • Ordering and/or performing diagnostic and therapeutic procedures;
  • Arranging patient referrals;
  • Delivering on-call care;
  • Performing physical exams;
  • Taking patient histories; and
  • Contributing to clinical decision making.

It is important to establish benchmarks to use when evaluating the person's performance.

Find the Right Candidates

The most direct way to find good NPP candidates is through job listings on the websites of local and national associations for physician assistants and nurse practitioners. (Check out http://www.aapa.org for the American Academy of Physician Assistants, and http://www.aanp.org for the American Association of Nurse Practitioners.)

Keep in mind that the two professions are always represented by separate associations. Another source of candidates may be local schools that train NPPs.

How to Compensate NPPs

According to the MGMA Research & Analysis Report, NPP Utilization in the Future of US Healthcare, in 2012 the median annual compensation for a primary case nurse practitioner was $94,062, and for a surgical physician assistant, $112,689. Their physician counterparts earned $207,117 (family medicine physician) and $367,885 (general surgeon) respectively. Practices have several payment methodologies. For instance, you might offer an annual salary based on the NPP's specialty and prorated for part-time. Or, you can choose an annual salary for full-time NPPs and hourly pay for part-time. The best option may be the one that incentivizes the NPP to work hard, such as a fixed-base salary plus bonuses for meeting or exceeding production goals.

What to Do Once You Hire a NPP

After you have interviewed and hired your NPPs, you will need to introduce them to two critical constituencies: Physicians and patients. When introducing them to doctors, clarify how the NPPs will fill your practice's gaps in care. Then define the roles for physicians and NPPs and document applicable standing orders, protocols, collaborative agreements and supervision agreements. Last, send letters to patients explaining the hire of NPPs and the role they will play. Physicians should introduce the NPPs to their patients during their next visits.

How to Get Paid for NPPs' Services

For Medicare patients, an NPP can bill for services in two ways:

  1. "Incident to" a physician's care, using the doctor's National Provider Identifier (NPI); or
  2. Directly after being credentialed by Medicare, using the NPP's own NPI.

Under the first option, after an initial visit by a doctor, the NPP can provide services under the physician's direct supervision or while the doctor is available in the office to give immediate assistance. To continue billing subsequent visits with the NPP as "incident to," the physician must actively participate in and manage the patient's treatment, with commensurate documentation in the patient's medical record.

Unless all of an NPP's services fall within the "incident to" definition, the NPP must use the second option — that is, to enroll in Medicare, obtain an NPI and bill directly. NPPs who bill directly receive lower reimbursements than when they bill "incident to." It is 85% of the full physician fee schedule rate vs. 100%.

Billing Commercial Payers for NPPs' Services

Private commercial payers have their own rules about reimbursing NPP services. They usually apply separate criteria for credentialing NPPs, sometimes not allowing them to bill directly.

Plus, they typically reimburse NPPs at lower rates than for supervising physicians. Your practice must bill under the doctor's NPI and follow the billing guidelines in the payer's provider manual. And you may need to append certain modifiers to the bill to correctly identify the NPP and supervising physician providing the care together.

Failure to satisfy the billing requirements of either Medicare or a private payer can create serious compliance problems for a practice. Regularly consult the websites of the Centers for Medicare and Medicaid Services and relevant private insurers to stay up to date on NPP billing rules.

Think About It

NPPs can bring substantial value to a practice, lightening doctors' workloads and bringing in some fresh perspective. But integrating them into your operations and reimbursing them can be tricky. If you are intrigued by the concept, discuss it with your practice's leadership and business advisors.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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