APA has joined an AMA-led coalition that is petitioning the Health Care Financing Administration (HCFA) to enforce a federal Medicare law requiring advance practice nurses (APNs) to collaborate with physicians.

The petition charges that HCFA pays APNs for Medicare services without knowing whether they are complying with the Social Security Act. The law requires APNs to obtain medical direction and supervision from a physician and defers to state law to define the precise arrangement.

"This is yet another example of HCFA not enforcing a law designed to protect patient safety and ensure access to comprehensive health care services," said Jay Cutler, J.D., director of APA’s Division of Government Relations.

A law enacted in 1989 allows psychologists to bill Medicare directly for their services on the condition that they consult the patient’s primary physician before initiating treatment. APA proposed to HCFA then that it enforce the law by requiring psychologists to document the consultation in the patient’s file that is available to HCFA.

"A decade later, we have not seen HCFA implement our proposal," said Cutler.

Because APNs bill the Medicare program using the same codes as physicians, it is imperative that HCFA develop and implement a system to monitor their compliance with collaboration and state scope of practice requirements, emphasized the AMA coalition.

Since the Balanced Budget Act was enacted in 1997 allowing APNs to bill Medicare directly for outpatient services, there has been a dramatic increase in the total allowable charges for CPT codes 99214 and 99215 (outpatient visits for established patients), the petition states.

APNs billed $2.1 million in 1998 for the two codes, compared with $700,000 in 1997, according to the AMA petition.

Because these codes can involve complex medical decisions, the coalition urged HCFA to enforce the collaboration requirement.

The AMA coalition also found evidence to suggest that Medicare is paying APNs for services performed outside of the APNs’ scope of practice. For example, Medicare paid 206 claims to APNs in Pennsylvania in 1998 for CPT code 90862, which is a psychiatric code for pharmacologic management. The code covers prescription use and medication review with minimal psychotherapy, according to the petition.

"Interestingly, in 1998, Pennsylvania did not allow APNs to prescribe medication," states the AMA coalition. Although the state law is being changed to allow APNs to prescribe medication, they must still collaborate with physicians, according to the petition.

Because HCFA does not keep track of state scope-of-practice laws for APNs, it doesn’t know whether APNs are in compliance, complained the AMA coalition.

Clearly, HCFA knows the Medicare conditions for payment to APNs because its 1999 regulations state that outpatient care (Part B) is covered provided the services performed are within the APNs’ state-mandated scope of practice and conducted in collaboration with physicians, according to the AMA petition.

In addition, the vast majority of states through regulation or law require APNs to collaborate with physicians and obtain physician input regarding the scope of the collaboration.

In the few states that lack collaboration requirements, the AMA coalition recommended that HCFA require APNs to submit documentation with their Medicare claims describing in detail their qualifications and responsibilities and the physician’s qualifications and terms of collaboration, according to the petition.

The AMA coalition also called on HCFA to take these actions:

• Implement a mechanism to monitor APN compliance with federal and state laws and instruct its carriers to do the same.

• Limit the distribution and renewal of Medicare billing numbers to APNs who comply with the federal and state requirements.

• Conduct an immediate audit of Medicare payments to APNs and then periodic audits to ensure compliance with the relevant laws.

"Compliance with collaboration and scope-of-practice requirements is crucial to ensure access to comprehensive health care services, patient safety, and confidence in a changing health care system," states the AMA coalition.