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Washington Watch

American Journal of Nursing - November, 2000 - Volume 100, Issue 11

Nursing Organizations Unite
Opposition to the AMA’s petition is strong

By Sheila Abood, MS, RN

Nursing groups across the country have united to counter ongoing efforts of organized medicine to define and control the scope of practice of advanced practice nurses (APNs). The latest of these efforts came this summer when the American Medical Association (AMA) filed a “Citizens’ Petition” with the Health Care Financing Administration (HCFA), which regulates Medicare. The petition is an attempt to pressure HCFA to take action regarding the Medicare rules for reimbursement and scope of practice of nurse practitioners (NPs) and clinical nurse specialists (CNSs) who provide Part B Medicare services. Signed by physicians representing 49 medical specialty organizations and state medical associations, the petition charges that “By failing to implement the [existing] law, HCFA may well be improperly paying NPs and CNSs for services rendered to Medicare beneficiaries.”

Leading nursing organizations, including the ANA, agree that implementation of the actions recommended in the Citizens’ Petition would limit APN practice, further reducing the access Medicare beneficiaries have to their services. Specific concerns focus on the petition’s prescriptive recommendations, which call for the development of protocols for Medicare carriers (health care organizations, such as GHI, that administer Medicare benefits) to verify and document NP and CNS compliance with physician collaboration requirements. The petition recommends that NPs and CNSs be required to complete an additional form that documents “background information about the collaborating physician(s), the authorized APN functions and any limitations on these authorizations, the process in place for developing joint guidelines, the availability of the physician(s) for consult, process for case and medical record review, and compliance with state law scope of practice requirements.” An immediate baseline audit would be conducted, followed by future periodic audits, “to ensure that Medicare payments to NPs and CNSs are limited to services furnished in collaboration with a physician and within their state law scope of practice requirements.”

UNIFIED NURSING RESPONSE

Tying NP and CNS practice to physicians in such a detailed manner would defeat the purpose of Section 4511 of the Balanced Budget Act, which, says ANA president Mary E. Foley, MS, RN, “was intended to expand access to health care services for currently underserved Medicare beneficiaries. “The petition would undermine that intent and restrict access to care for those Medicare beneficiaries who so desperately need it.”

The ANA House of Delegates has voted to oppose the Citizens’ Petition and to extend support for the ability of APNs to secure Medicare reimbursement in both independent and interdisciplinary practice. They also agreed to initiate and support ongoing efforts to obtain accurate information regarding the actual extent of APN services under Medicare. Since then, representatives of 10 nursing organizations have joined forces to craft a strong message for HCFA that reaffirms the nursing community’s support of APNs’ ability to bill Medicare without facing costly, burdensome, and unnecessary restrictions on their practice, including physician supervision. More than 200 national and state nurses organizations signed on to the comments.

The comments of the House of Delegates emphasize that nursing and HCFA share common goals: ensuring Medicare beneficiaries access to the services of NPs and CNSs and protecting Medicare from fraudulent billing practices.

The extension of Medicare coverage of NP and CNS services to all geographic areas and treatment settings resulted from public and congressional support. In fact, NPs have been billing the Medicare program for services provided in rural areas since 1990 without the adverse effects the AMA is predicting.

According to the House of Delegates, there is no evidence showing NPs or CNSs “practicing beyond their legal authority or inappropriately billing the federal health programs. . . .” Nor is there any “sound rationale to support additional federal regulation of NP and CNS practice.”

The AMA Citizens’ Petition

The response of the House of Delegates