Reimbursement of Advanced Practice Registered Nurse Services

In order for the APRN role to survive in many settings, a revenue stream may need to be developed. There are increased opportunities for billing of APRN services and it is important that APRNs understand the issues involved in capturing third party reimbursement. There are many legal and financial issues that need to be appreciated by the APRN as they relate to reimbursement. Reimbursement is a complex structure that includes regulatory factors both at the state and federal level. For example, APRNs may bill Medicare under the physician payment system only if the APRN has the legal authority under state law to perform the service to be billed (“Balanced Budget,” 1997). Clarification on the issue of legal authority will be covered under the definition of an advanced practice nurse, since states license APRNs, there is variation between states on the definition of an APRN. Rules for billing are complicated, scattered throughout Federal and State law, and vary from payer to payer (Buppert, 2007). While this fact sheet will cover Medicare billing regulations, many insurers will follow Medicare guidelines. However, the APRN should remember that insurers may regulate reimbursement in their own way.