Literature Review

Systematic review addressing nurse practitioner reimbursement policy: Part one of a four-part series on critical topics identified by the 2015 nurse practitioner research agenda

Harkless, Gene DNSc, APRN, FAANP, CNL (Associate Professor & Department Chair)¹; Vece, Loretta DNP, APRN, FNP-BC²

¹Department of Nursing, University of New Hampshire, Durham, New Hampshire; AANP Research Committee,

²PediatriCare of Northern Virginia, Haymarket, Virginia; George Mason University/Mason and Partners Clinics, Fairfax, Virginia; AANP Research Committee

Correspondence: Gene Harkless, DNSc, APRN, FAANP, CNL, Associate Professor & Chair, Department of Nursing, University of New Hampshire, Durham, NH 03824; Fax: 603-862-4771; E-mail: [email protected]

Author contributions: G. Harkless did the initial draft of the Methods and PRISMA tables. G. Harkless worked with the research librarian to procure sources and provided direction throughout the processes. L. Vece did the initial draft of several sections of the manuscript and created the tables. L. Vece and G. Harkless both individually read and reviewed all articles and completed Briggs and Hopkins evaluations, consulted, and decided on plan and directions for the article before the initial draft. After the initial draft, the article was then jointly revised and made publication ready.

Competing interests: None of the authors declared any competing interests or conflicts of interest.

Journal of the American Association of Nurse Practitioners 30(12):p 673-682, December 2018. | DOI: 10.1097/JXX.0000000000000121

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Abstract

Background and purpose:

The growth and sustainability of nurse practitioners (NPs) requires transparent, fair and equitable reimbursement policies. Complicating this issue is variation in reimbursement policy within and across federal, state, and other payers. Even with explicit regulations, there remain questions on how reimbursement policies are covertly operationalized in practice. This systematic review aims to identify knowledge gaps related to reimbursement policy issues and outlines recommendations for further research.

Methods:

Eight major databases were searched using terms including “nurse practitioner,” “reimbursement,” “policy,” and “research,” limited to the United States and inclusive of December 2006–September 2017. Articles meeting the inclusion criteria were analyzed for themes and gaps.

Conclusion:

The final review includes 17 articles identifying themes including state-determined Medicaid reimbursement and scope of practice legislation shapes NP clinical practice; NPs as identified primary care providers: credentialing and contracting; reimbursement parity; and “incident to” billing. Moreover, there is evidence of discriminatory policies that disadvantage NPs and limit their access to patients, direct billing, and direct reimbursement.

Implications for practice:

Future research needs to focus on outcomes of discriminatory, as well as supportive, reimbursement policies in organizations, and their influence on patient access and quality care.