The physicians of Fairview Medical Group met to consider hiring a Non-Physician Practitioner (NPP). The internists reported that their same day appointments filled up fifteen minutes after the phone lines opened each day, leaving scarce available appointments for acute visits. Physical exams were scheduled months ahead. The General Surgeons wanted help with post-operative visits. The surgeons pointed out they could perform more surgery if they had an NPP to do post-op care. The practice manager was in agreement. The idea seemed promising when someone asked, “What are the rules for billing an NPP?” insurance credentialing and contracting
A long silence was the only response. The doctors charged the practice manager with researching the question and reporting back at the next board meeting.
Fairview’s insurance mix was 40% Medicare, 10% Medicaid, 20% Man’s Greatest Insurance, 18% Green Arrow, and 12% commercial insurance with which the practice had no contract. At the next meeting, the manager reported that Man’s Greatest Insurance enrolled and credentialed NPPs. For patients with this insurance the group would bill under the NPP’s number. This company offered to
pay 85% of the fee schedule amount, but the manager believed that other groups in the state had successfully negotiated a full fee rate for NPP services. Green Arrow did not credential or enroll NPPs. Their on-line provider manual stated only that the NPP should operate within their state scope of practice and have a collaborative arrangement with a physician. For Green Arrow, the practice would bill under the MD’s provider number, and receive full reimbursement. If there was no contract with an insurance company, the group would bill under the physician’s provider number.