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Nurse Practitioner Practice Management - Susan Cooper
Susan Cooper is the Administrative Director (1998 -) of the Vanderbilt Medical Group Network Practices in Nashville, TN. As the Administrative Director, Susan works closely with physicians, nurse practitioners, and staff to develop and implement operational plans for practice management and strategic development. Prior to serving as the Administrative Director at VMG, Susan was the Director of Health Services (1994 - 1997) for Phoenix Healthcare of Tennessee when it was a fledgling managed care organization and assisted in the development of the commercial and TennCare managed care plans. Susan's foundation in healthcare was established as a nurse in the intensive care unit and emergency room where she worked in several hospitals across the Midwest.

Susan also serves as an Assistant Professor (1998 -) at Vanderbilt School of Nursing where her specialty is Health Systems Management. As part of the Health Systems Management curriculum, Susan lectures and develops content for a variety of classes that include Continuous Quality Improvement, Financial Management, Case Management, Community Systems Management and Theoretical Foundations of Nursing Administration.

Susan is a published author and often tapped for speaking engagements. She lectures nationally for the American Association of Managed Care Nurses on the subjects of Medical Informatics, Negotiation Skills and Nursing in the 21st Century. Susan has also shared her managed care expertise in a presentation for the Japanese Federation of Social Insurance Associations.

Susan received her Master of Science in Nursing and Bachelor of Science in Nursing from Vanderbilt University School of Nursing.


Question 1 - Hello Susan, Are Nurse Practitioners balancing their care practices with the business side of their practice? Do they understand the financial components of running their business/practice? What are some of the common financial components a NP would need to focus to stay close to the financial side of their practice? What are some of the areas for improvement where NPs fall short in this area? Are their NP practices that are closing due to poor management of their financial practice? Thanks by tammy on April 24, 2000

Answer 1 - Thanks for the question. There are many advanced practice nurses who are financially savvy and those who are not. Reimbursement issues for nurse practitioner and nurse midwifery services are very complex. Reimbursement policies of the third party payers are the determining factors for financial viability of an advanced practice nurse's practice. The foundations for developing fiscal awareness are found in the contractual languafe with the health plans with whom an APN contracts. Advanced practice nurses (APNs) need to understand the terms of their contracts with the third party payers since the policies and fee schedules vary across plans. Components of the contracts that need to be understood include:(1) credentialing: does the health plan credential APNs as independent practitioners,does the plan credential APNs as primary care providers only or do they credential specialty APNs, does the health plan credential APNs at all; (2) Reimbursement: does the plan reimburse APN's directly (under their individual provider number) or does the plan require the APN to bill services "incident to" a physician's services, a definiton of "incident to", reimbursement methodology (capitation, discounted fee for service, RVU based methodology), are there any withholds or panel management fees (payable to the primary care providers, etc. (3) operational requirements: covered and noncovered services,precertification, referral, and authorization requirements,number of days the APN has to submit a claim,appeals process for denied claims. Advanced practice nurses must also have an understanding of anticipated, as well as actual, revenues and expenses. It is not unusual for nurse practioners to enter into a business relationship without first developing a business plan/model for their practice. In order to be financially sound, the APN must generate enough revenue to cover both direct and indirect expenses such as salary, benefits, support staff, rent, utilities, malpractice insurance, supplies, telephones, computer support, etc.

A common misconception is that billed charges equals revenues. Productivity issues must also be explored within the practice to determine if there is enough volume to generate enough revenue to cover expenses. It is difficult to cover the entire "business side" of practice in a few short sentences. I would recommend to any nurse practitioner a wonderful resource book Nurse Practitioner's Business Practice and Legal Guide by Carolyn Buppert. It contains detailed information about practice managment and legal issues affecting nurse practitioners. by Susan Cooper on April 25, 2000
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Question 2 - Hi Susan, I'd like to ask you to put on your Medical Informatics hat and respond to the comments at the bottom of the article in today's tech section, titled "Consumers Ahead of Providers." The author characterizes the new tele-savvy consumer as a provider burden, which I believe may AND may not be true. They ask their providers more questions, want to engage in deeper dialog about clinical options, and take up the same amount of time in an e-unbillable fashion. The British National Health Service is reportedly experiencing a strain in part due to the same issue: consumers who frequent the internet health sites place more demands on their providers. Two questions: What kind of new credentialled roles will this create in health care? Are any of the Medicare Conditions of Participation addressing practice standards and safeguards for telemedicine applications? by TRyndes on April 24, 2000

Answer 2 - What interesting questions! The healthcare environment is in a constant state of change. To meet the needs of our patients, providers must reconsider and expand their roles. Consumers are demanding a participative role in making decisions about their health status and the internet is a readily accessbile means to that end. Traditionally, healthcare information was held in journals housed in "medical libraries" which were not easily asccessible to consumers of care. With the explosion of healthcare information on the internet, access is not limited. This does,however, create new demands on providers. But the new demands are not one sided. Consumers are feeling the crunch of productivity based models of care, limiting face to face contact with their providers. Consumers/patients feel the need to be educated about choices, diseases, medications, options,so that their time with a provider is used wisely. I see the roles of providers expanding, moving to a model that includes being "brokers" of evidenced based internet information. Wouldn't it be wonderful, if providers could have a patient education tool that lists websites specific to their concerns. There are such massive amounts of information on the internet that consumers are looking toward us to help point them in the right direction. In fact, we have an obligation to those patients/consumers that we serve to provide access to sites which have information specific to their needs and based on data. What new credentialed roles will evolve, I do not know. I cannot speak to the Medicare Conditions of Participation for practicing telemedicine. You might search the medicare website http://www.hcfa.gov for information on the topic. Thanks for the interesting questions. by Susan Cooper on April 25, 2000
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Question 3 - Hello! I was wondering... in general, or in your experience, is there much support or enthusiasm for Nurse Practioners to develop web sites of their own for patient use/education? Do you know of any who are set up that way? In the NP educational curriculum, is any time spent on the Internet and how it can be a useful tool for the healthcare practioner? What are your thoughts on this? Thanks!! by Ingolfsson on April 25, 2000

Answer 3 - There is great enthusiam for practice specific website development for providers of all types. Technology now exists for patients to schedule appointments over the internet, request prescription refills, register for and attend classes, check on provider participation in specific health plans, etc. However, few providers have developed the skills necessary for building a website. It is helpful to learn these new skills in a "safe environment" where you can learn from your mistakes. Rarely have I seen a "first effort website" arrive in perfect or final condition. Many schools of nursing are integrating information technology into their programs. However, before you can expect the students to become proficient, there is education needed at the faculty level so that they may assist students in their efforts. Development of courses offered over the web require a different skill set than those needed for delivering a face to face lecture. The Health Systems Management specialty at Vanderbilt University School of Nursing has a required informatics course for students...They also utilize electronic conferencing, video streaming of lectures, and development of websites in several of their classes. Also, there are many nursing courses that use internet searches to teach students about accessing health information on the web. Through these exercises, future nurse practitioners can begin to evaluate and critique those websites that might be of benefit to their patients for educational purposes. It is quite important for practicing APNs to learn to search payer sites for information related to credentialing, precertification and referral requirements, and new policies and procedures that may impact their practices.

Nurse practitioners and certified nurse midwives should take the opportunity to develop sites that educate both patients and providers on the APN role. One site I found interesting is http://npo.oregonrn.org/index which contains information on the role of nurse practioners as well as patient education information. An example of a helpful payer site is www.cignamedicare.com. It is extremely important to stress that all providers should begin to research the new HIPAA regulations related to transfer of patient information over the internet and security requirements. by Susan Cooper on April 25, 2000
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Question 4 - I am interested in your opinion on how the political/legal/ethical fight about NPs will come out in the end. I am thinking of the New York battle where some successful NPs were accused of practicing medicine without a license. I am also thinking of those areas of the country where a NP can be more autonomous if the population is undeserved and no physician is willing to come. I am mindful of the research that shows how much patients like the nursing model. Certainly a NP isn’t more likely to “cross” that line into medical practice in a (successful) urban practice versus one in a rural or undeserved area. Perhaps I am cynical but it seems these battles often turn on money. If a savvy group of NPs is doing well it is more likely a question about crossing the line will be raised. What have we learned from all these skirmishes about how to promote the role? Collaborate? How to build beneficial mulit-speciality practices? Have we made in headway in realizing that both/all disciplines are valuable? Thanks. by pix on April 27, 2000

Answer 4 - We learn lessons every day. As you have beautifully articulated, economics play an important role in determining the dynamics of many physician and nurse practitioner interactions and we would be foolish to believe or to state that this does not occur. Conflict, however, is not occuring just between physicians and nurses but among all providers of care. Payments for services rendered are shrinking across the board and all providers of care...hospitals, physicians, nurse practitioners, home care, etc...are all feeling the pain in their pocketbooks. It becomes a matter or survival--meeting basic needs. This sets up an environment that is ripe for chaos and conflict.

An ideal strategy would be to develop collaborative practices defining clear scopes of practice and clear expectations. The key is collaboration. Physicians and nurses both have roles to fulfill in the care and treatment of patients. However, it cannot be an "us versus them" , "either/or" mentality but a "we" approach to providing care. The focus needs to change from what we can't do to what we can do together.

With economics playing such an integral role, we would all benefit from a strategy where physicians and nurses work together in the struggle with payors to develop win-win situation for all. We have the opportunity to participate in creating models of care for the future. No one model fits every practice situation, so we must be creative in our approach to developing models that create win-win situations for all.

Thanks for your very thoughtful and insightful questions.
by Susan Cooper on April 27, 2000
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Question 5 - Is there sometimes a conflict between nurse practioners and doctors, especially those doctors from "the old school"? I can see that happening.

What are some ways to deal with this, in your opinion? Or is it not enough of a problem today to really worry about? by annemarie on April 27, 2000 1:29

Answer 5 - The extent to which conflict exists varies. (See Q4) I do believe that potential conflict can be avoided or, at least, minimized if there is careful planning and preparation during new practice development. The key is collaboration. During the exploratory phase of practice development, there must be open, honest dialogue between all involved providers and administrators.

Concerns must be articulated. A business plan based on data is helpful, however many practices skip this step. Scopes of practice and roles must be defined in writing. Definition of employment relationships must be clear. Is the advanced practice nurse functioning in an independent provider role with physician preceptor backup or is the role one of a physician extender? Are the services provided by the nurse practitioner billable to your payers? How does reimbursement flow...to the provider of care, to the physician, to the clinic, etc.? How are direct and indirect expenses allocated? After due diligence is completed, someone needs to evaluate if benefits of entering into practice outweigh the costs or if costs outweigh benefits.

Most conflicts seem to boil down to 2 things...money (or lack thereof) or unclear definition of roles/scope(leading to the impression of oversteping ill defined boundaries). It takes hard work by all involved parties to make any relationship work and practice situations are no different. by Susan Cooper on April 27, 2000
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Question 6 - Hello Susan, As a Long-term care director, I was wondering how a NP could be reimbursed if he/she was employeed by a nursing home with a skilled care unit. We have a great NP who works with the doctors that have patients there, but he is really interested in doing long term care only. I understand that a NP has to be employeed under the supervision of an MD. Is there a way that the nursing home can bill for his charges? by ltcnurse on April 27, 2000

Answer 6 - Great question. Long term care is the perfect setting for an advanced practice nurse with a specialty in geriatrics. We have had a very successful model for nursing home care with the nurse faculty practice at Vanderbilt. There is a collaborative relationship between a specific physician and GNP. The physician serves as preceptor and the GNP works under a set of protocols that are collaboratively developed. The GNP is present on site each day and takes call for the patients. She has her own Medicare provider number and bills Medicare directly for services provided. She is not an employee of the facility or the physician, but of the School of Nursing. There is a contractual relationship that delineates scope of practice, preceptor relationship, responsibilities, etc. Bills are submitted for GNP services only---No double billing--the NP and MD cannot bill on the same date of service.

It is important to understand your state's Nurse Practice Act and determine what applies to nurse practitioners in your state. You must be very clear about the Medicare rules and regulations on employment arrangements and reimbursement for services. It is important to differentiate what is covered by Part A of Medicare and Part B (professional services). I would suggest that you look at the Medicare rules and regulations for services included under the payment system for long term care and skilled nursing facilities. (I cannot speak to these). The reason I bring this up is that for hospital outpatient settings, nurse practitioners employed by the facility cannot bill separately for servies rendered. These services are bundled into the cost report. If he/she were an employee and billed for services, it would be considered double dipping and a compliance violation. This may or may not apply in your situation.

Also, you will want to assess who your other payers are. Each payer has a separate set of rules and regulations for how nurse practitioners must bill and if they will pay for services rendered by an APN. Medicare has taken the lead and hopefully other payers will follow. It would be wonderful if all payers would utilize a similar set of rules for reimbursement for services.

There is great interest by a number of companies in using geriatric nurse practitioners for services in long term care settings. Each setting is different and requires a detailed assessment. Consultants are available to assist with clarifying issues related to specific settings. If you would like further information about your specific situation, please email me through this forum and I will be happy to answer offline. by Susan Cooper on April 27, 2000
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Question 7 - Hello Susan, I have often noticed the nurse practitioners are left out of insurance provider panels. You are required to sign up under the physician yet make appointments with the nurse practitioner. Is this due to payor stipulations, federal law or credentialing requirements? (I realize each state may be different) Is there a movement to list nurse practitioners as providers and is it supported by payors or do they put up barriers?
by yvette on April 27, 2000

Answer 7 - The answer to your question is All of the above. You have identified one of the major obstacles that advanced practice nurses face on a daily basis. Unfortunately, payors do not treat advanced practice nurses in a consistent manner. Some payors credential APN's, assign a provider number, and allow the APN to submit bills in their name under their own id number. Some payers credential APN's, assign a provider number, but require the APN to submit a claim "incident to" the physician. Some payers do not credential APN's at all, but allow the APN to submit a claim for services rendered, again "incident to" a physician's services. Some plans just don't recognize APN's. Many plans have different policies and procedures depending on the scope of practice. They may credential APN's that serve as primary care providers and allow them to bill direct but require APN's with "specialty" training to submit claims for services "incident to"..Unfortunately, incident to guidelines often vary from plan to plan. It is difficult to get clarification in writing from many plans about APN credentialling and payment.

Medicare assigns Advanced Practice Nurses their own provider ID number and allow direct billing for services rendered by the APN. However, one must be aware that there are exclusions to this rule based on site of service. It is imperative for APN's to read and understand the Medicare guidelines for billing.

Unraveling these issues takes an enormous effort. Each health plan needs to be tackled one plan at a time. We have had success but it takes perseverance and stamina. There is an oppotunity for advanced practice nurses to start discussing these issues with health plans on a state by state basis, elevating the concerns with the "kinks" in the process to a national level. Maybe one day, requirements will be consistent across plans. by Susan Cooper on April 28, 2000
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Question 8 - Susan, I have been reading these questions and comments, very good information. Is there an online place where nurse practitioners can go to discuss issues and problem solve as a collective group? Not sure an ANP education provides all the information needed in running the daily operations of a practice. Was curious? by Luke on April 28, 2000

Answer 8 - I am not aware of an online community for advanced practice nurses. I am in full support of this concept and believe that there is a true need for us to work together. What we have found as we have discussed inssues with our colleagues across the nation is that we all face very similar problems. To my knowledge there is not a "central repository" problems identified and creative solutions for resolving the issues.

Advanced practice nursing education has traditionally included the clinical, physical, and psychosocial aspects of care, but the business side of practice has either been omitted or delivered in one or two hours survey lectures, covering glocal issues but not the "how to details". As we look at programs across the nation, I do see that we are trying to integrate the "business view" into the curriculum. However, this is not an easy process. In order to educate the APN students, you must first educate the nursing faculties, who in many cases are experts in academia or research but not practice operations management. I would love to see every APN program integrate this content into the curriculum and, perhaps, offer an elective on Practice Opportunities, Development, and Management.

I hope that one day soon we will see an electronic site that can bring APN's from around not only the country, but also the world to discuss practice issues. We have a great deal of knowledge to share. Now is the time for the dialogue to begin. If you would like more information, please email this site and I will be happy to contact offline. Thanks for the great question. by Susan Cooper on April 28, 2000

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