It happens all too often. A CHC searches the state Medicaid site for policy clarification and they find information opaque as mud. Are nurse visits encounter rate eligible? Are vaccinations as a stand-alone service payable? Are NP services billed under their own NPI or “incident to” under a physician’s number? Confusion is rampant and clarity wanting.

In two recent scenarios, we researched items for clients and by using inference due to absence of overt statement and federal statutes we were able to arrive at an answer that seemed at least defensible, if not even logical.

Nurse visits in numerous states are listed as encounter rate “eligible.”  In other words, the Medicaid FQHC “core provider” definition either explicitly lists a nurse (sometimes only listing a Registered Nurse vs. a Licensed Practical (Vocational if in CA) Nurse) and/or
it indicates that a nurse or other ancillary staff service rendered “incident to” a physician’s oversight is encounter rate eligible.  Yet, when seeking written clarification from these states, we have waited years (for Connecticut it is two plus years and counting) without a response.

The result is CHCs inconsistently coding for nurse services with some sites getting paid encounter rate for nurse work and others NEVER even coding a nurse service out of fear that it might be “illegally” reported. When clarity is missing, it does make sense to follow the more conservative route… but only if your senior management team is very risk averse. Other CHC sites use the ambiguity as justification for additional remuneration. In the end, and in support of the conservative option, Medicare only allows encounter rate payment for services rendered by defined core provider. Nurses are not core providers… Period.
However, Managed Medicaid and Managed Medicare (Medicare Advantage) most often
pay for nurse and other ancillary staff services so being certain to capture the clinical event is critical to optimize cash flow AND appropriate demonstrate the full breadth and scope of rendered services. If “wrap payment” is available these non-core provider services are normally ineligible. This necessitates the ability to delineate between what is and is not “wrappable.”

In Michigan, we were recently asked for clarification about NP services. Specifically, should NP services be billed under a NP’s unique, individual NPI or under the Medical Director’s (or any other employed physician’s) NPI. Our advice was that it should be billed under the NP’s NPI. This client came back to us a couple of months after our report which included this directive asking for our resources and justification as the state just published a Medicaid Policy Update mandating NPs bill under their unique, individual NPI as of
October 1, 2012. How, the client asked, did we arrive at our recommendation when the state is clearly arriving at this policy and not for another couple of months? Following is our “logic” resulting in our recommendation:

1. In the second paragraph of the attached document the following directive exists:  “Individual providers (doctors, dentists, optometrists, etc.) are required to obtain a Provider (Type 1 -
individual) NPI number and report the number to MDCH.”
2. While NPs are not specifically listed, there does exist a directive from the MI State NP association which concurs with the quote in item 1. above; i.e., the directive advises NPs to bill Medicaid using an individual NPI vs. billing under a ‘supervising provider”.
3. In the first paragraph of Section 1.5 (Non-Enrolled Provider Services) of the attached Medicaid Manual, the following statement exists: “Professional services provided by FQHC clinical social workers, clinical psyhcologists, and physician’s assistants are reimbursed under the PPS. Since MDCH does not directly enroll these providers, claims for their services must be billed using the NPI of the supervising physician responsible for ensuring the medical necessity and appropriateness of the services.”
4. MI Medicaid makes a point of clearly stating the MDCH does not enroll providers listed in item 3. above. Since Nurse Practitioners are not listed in this section 1.5, by inverse deduction, it can only be assumed that NPs are part of the provider group listed in item 1. above.
5. As presented in the proposed MI Medicaid update scheduled to be effective 10/1/12, NPs are encouraged to submit under their own individual NPI. It is PMG’s contention that unique NPI submission by NPs in MI was always the intent/desire of MI statute. This recent proposal is simply offering clarity to existing documentation which was wanting in terms of clarity.
6. Finally, whenever PMG encounters state statute/legislation which is unclear, reverting to Federal policy is standard protocol. As such, NPs have had the ability to submit claims under a unique NPI (originally a UPIN) since the BBA of 1997 afforded such, effective July 1, 1998. While PAs were also included in this BBA policy update, the state of MI clearly excluded such option for PAs based on the language in Section 1.5 reiterated in item 3. above. As such, again, PMG remains firm in its opinion that NPs should be submitting claims to the state of MI under their unique NPI vs. under the NPI of a CHC medical director or other CHC physician.

Is this content circuitous? Maddening? Headache inducing? Yes, yes, and yes. However, without clear guidelines from state Medicaid, and CHCs working diligently to be compliant… there really are no other options.

A final example involves vaccinations… if your CHC is in a state that, to some degree (regardless of language clarity), affords encounter rate reimbursement nurse visits… what services are eligible. The first response is ALL services, right? Again, without clarity, we recommend a default to federal policy. Medicare does not allow encounter rate payment to a CHC for “vaccine only” visits. As such, we would argue that even a state that pays (or at least looks they might pay) for nurse visits, vaccines would be excluded from this option
due to the federal policy setting precedent against such.

Is there latitude or wiggle room? Certainly. However, it has always been PMG’s position that to push the envelope with the feds is creating an opportunity for dialogue on potential discrepancies with not provider relations filed reps from BCBS or United but instead, the FBI. NEVER overstep potential boundaries when governmental dollars are involved. Punishment (or at least certainly public accusation) is swift, can be hefty, and is avoidable by following a conservative interpretation of this vexing, ambiguous policy.