Medicare Reimbursement for Nurse Practitioners

Nurse Practitioners (NPs) share many roles with physicians, including diagnosing diseases, treating patients, managing both acute and chronic medical conditions, and interpreting patient lab reports. Although they sometimes perform identical roles, when it comes to Medicare reimbursements, the NPs receive a lower share compared to their counterpart. For instance, a physician and NP will receive $100 and $85 for the same patient, respectively (Decker, 2018). This paper discusses Medicare reimbursement for NPs with a focus on the process of changing the current policy.

Medicare is a federal health insurance program targeting specific individuals and groups. It is similar to Medicaid in the sense that reimbursement rates are based on a fee schedule (Schatzle, 2016). However, Medicaid is a joint state and federal program with rates that vary by state. Medicare provides coverage to people who are 65 years and above and those with severe disabilities. Such factors as first-time visits to a facility, own insurance provider, and membership to a clinic dictate the amount a nurse practitioner and a physician get reimbursed on the individual patient.

The uneven Medicare and Medicaid reimbursement returns between NPs and physicians remain a contentious issue. The policy on the amount that goes to the physicians and NPs should change. This argument can be supported by the idea that having an individual being reimbursed 85% as the law requires discourages health facilities from hiring NPs and instead more physicians. The varying pay rates are disadvantageous to the nursing practice at large. Besides that, changing the rate of reimbursement would benefit not only the NPs but also healthcare facilities and the healthcare population. Such a policy change would increase access to much-needed services (Schatzle, 2016). NPs can be able to establish individual practices making healthcare readily available to the general population. Lastly, the policy has been in place for the last two decades despite there being a lot of changes in the nursing practice and health sector (Decker, 2018). In this case, doctors are not justified to have a higher reimbursement as compared to the NPs as both roles are intertwined.

In order to change the policy, the same process and people that passed the bill have to be involved. A bill has to be prepared and presented to Congress which will then decide whether the changes should be implemented. If the bill is endorsed, it will be passed into law ensuring favorable reimbursements for NPs. The current rates impact NPs negatively and limit their career advancement (Barnes et al., 2016). For example, the NPs may not be able to establish independent practices as they would receive unfavorable reimbursements.

There are several major players in health policy reform. First, NPs can have a significant influence on this matter because they provide patient care. Second, Congress is another primary stakeholder as it has the authority to decide whether the proposed changes will be enacted into law. Major groups opposed to this change include insurance companies and physicians because they are the main beneficiaries of Medicare reimbursement returns. For example, despite sharing major job functions and roles with NPs, physicians’ rates are far higher than the average reimbursement returns for NPs.

Several AP roles may be helpful in influencing the policy change. Typical roles of NPs include prescribing medications, ordering medical tests, and diagnosing diseases (Decker, 2018). In comparison, APs are mandated with a more nuanced scope of diagnosis and treatment of health conditions. In this regard, certain roles such as diagnosis of health conditions, treatment and management of acute and chronic diseases, and prescription of medication give the physician an added advantage. However, with the ability to provide patient care, physicians may not have a strong argument in opposing the proposition (Barnes et al., 2016). Therefore, it is unfair to ignore the need for equal and fair reimbursement of NPs.


Barnes, H., Maier, C. B., Altares Sarik, D., Germack, H. D., Aiken, L. H., & McHugh, M. D. (2016). Effects of regulation and payment policies on nurse practitioners’ clinical practices. Medical Care Research and Review, 74(4), 431–451. Web.

Decker, S. L. (2018). No association found between the Medicaid primary care fee bump and physician-reported participation in Medicaid. Health Affairs, 37(7), 1092-1098. Web.

Schatzle, R. (2016). Nurses receive lower Medicare and Medicaid reimbursement returns compared to physicians. Medelita. Web.

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