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The Future of Nursing: Leading Change, Advancing Health
if state rules require physician supervision of NPs in hospitals,
if medical staff bylaws interpret “clinical privileges” to exclude “admitting privileges,” or
if hospital policies require a physician to have overall responsibility for each patient.
A nurse may not be:
empaneled as a primary care provider for Medicaid or Medicare Advantage managed care enrollees;
included as a provider for covered services for Workers Compensation;
Current laws are hampering the ability of APRNs to contribute to innovative health care delivery solutions. Some NPs, for example, have left primary care to work as specialists in hospital settings (Cooper, 2007), although demand in those settings has also played a role in their movement. Others have left NP practice altogether to work as staff RNs. For example, restrictive state scope-of-practice regulations concerning NPs have limited expansion of retail clinics, where NPs provide a limited set of primary care services directly to patients (Rudavsky et al., 2009). Similarly, the roles of NPs in nurse-managed health centers and patient-centered medical homes can be hindered by dated state practice acts.
Credentialing and payment policies often are linked to state practice laws. A 2007 survey of the credentialing and reimbursement policies of 222 managed care organizations revealed that 53 percent credentialed NPs as primary care providers; of these, 56 percent reimbursed primary care NPs at the same rate as primary care providers, and 38 percent reimbursed NPs at a lower rate (Hansen-Turton et al., 2008). Rationales stated by managed care staff for not credentialing NPs as primary care providers included the fact that NPs have to bill under a physician’s provider number, NPs do not practice in physician shortage areas, NPs do not meet company criteria for primary care providers, state law does not require them to credential NPs, and the National Committee for Quality Assurance (NCQA) accreditation process prevents them from recognizing NPs as primary care provider leads in medical homes. As discussed above, some states require NPs to be supervised by physicians in order to prescribe medications, while others do not. In this survey, 71 percent of responding insurers credentialed NPs as primary care providers in states where there was no requirement for physicians to supervise NPs in prescribing medications. In states that required more physician involvement in NP prescribing, insurers were less likely to credential