Self -employed Registered Nurses as Private Practitioners, a Career Option

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Private Nursing Practice meaning self-employed Registered Professional Nurses (RN’s) is a career option which is a meaningful and significant practice model for all of America’s RN’s. RN’s meaning the original, typical Registered Nurses who are the rank and file of the nursing profession, the majority of America’s nurses, three million plus.

This model of RN practice isn’t taught in nursing schools nor has it been in vogue for years since its advent in the 1970’s and 1980’s. RN’s are not cognizant enough of this nor that America’s rank and file RN’s are not quoted in our public health insurer’s fee schedules for reimbursement for providing nursing services to their patients.

These payments are third party payments; this is how physicians and other providers are paid by our three public and our private health insurers. Third party payment means the patient is one party, you the provider is a second party and the insurer is the third party who pays the provider, the second party for their services to your patients.

Our three public health insurers are Medicaid per each state; Medicare that the Federal Government provides for all states and the Affordable Care Act (ACA) (Obama Care). Medicare is discussed since it may be the best public health insurer to have our federal government quote all rank and file, typical RN’s in our Medicare fee schedule for reimbursement to these RN’s for their nursing care to Medicare patients. This means that rank and file RN’s and all RN’s who provide nursing services to Medicare patients could bill Medicare for reimbursement for their nursing services that are in Medicare’s fee schedule the way Medicare requires this billing. This should include all future public health insurance programs as well.

You should work to have rank and file RN’s and all RN’s quoted this way in Medicare; contacting politicians helps. “The whole orientation of these services is to provide low-cost, quality nursing care and counseling to prepare patients for self-care.” (1)

My private nursing practice opened in New York State in 1972. (2), (3). Patients were billed fee-for-treatment, the same as fee-for-service. My patients paid me themselves, care was provided gratis to the indigent. You can maintain a traditional nursing job and practice privately from your Nursing Office (Nursing Practice) accepting patients by appointment during hours you are off from your traditional nursing position. You can accept walk-in patients. Take your patients history, contact their physician for orders for nursing care as needed scheduling a future visit for nursing services is best. Walk-in patients with emergencies can be provided emergent care if possible. Call 911 for an ambulance to transport these patients to emergency rooms which you are not. Your nursing practice isn’t an emergency room; you primarily schedule appointments providing only nursing services you are competent in and licensed to provide.

A few selected Nurse Practitioners (NP’s) and Advanced Registered Nurse Practitioners (ARNP’s) are quoted in Medicare’s fee schedule for only a few services. This should be changed to include America’s millions of typical, rank and file Licensed Registered Professional Nurses, RN’s, who are always Licensed to Practice Registered Professional Nursing to include nursing services they are licensed to provide. Create a list of nursing services you provide as an RN and attach a fee you would charge for each to realize the value of the vast amount of nursing services you could provide being self-employed.

“New payments will be awarded to Nurse Practitioners, Clinical Nurse Specialists, Certified Nurse Midwives and other primary care professionals for ‘transitional care management’ services provided within 30 days of a Medicare patient’s discharge from a hospital or other similar facility.” (4) This Medicare rule has limited reimbursement for Registered Nurse Anesthetists and Advanced Practice Registered Nurses. This is absent reimbursement for the millions of our rank and file RNs’ and their vast amount of professional nursing services they can provide for the public cost effectively. This absence of rank and file RN reimbursement is evidence that Medicare doesn’t reimburse RN’s for their nursing services prohibiting rank and file RN self-employment.

The absence of RN’s for this reimbursement may be discriminatory limiting nurses’ careers and employment options that’s similar to the private practice of other health care providers who are so quoted and prohibits rank and file RN’s from providing cost effective professional nursing services to the public which keeps health care expensive.

RN’s can provide care to patients in their Nursing Offices (Private Nursing Practices) and by home visits. Home visits are cheaper than the cost of Medicare paying an ambulance to transport patients to and from home to physician’s offices for the physician or their nurse to provide similar care at a higher cost than self-employed nurses may charge.

“As the demand for medical services grows, advanced practice registered nurses, or APRNs, are going to occupy more prominent positions in the provider community. In order to remove some of the professional and practical barriers that exist for those who choose nursing careers, the Medicare Payment Advisory Commission (MedPAC) is contemplating policies that would improve payment rates for both APRNs and physician assistants, as reported by Medpage Today.” (5). This evidence shows the absence of our rank and file RN’s from Medicare’s fee schedule for reimbursement for their services.

Many RN services overlap with physician services which RN’s can provide cheaper. Many RN roles are esoteric that physicians don’t provide which RN’s can provide cost effectively. Not all RN’s may want to practice this way; they all should be aware of this and have this opportunity. Many physicians are pleased to have RN’s provide nursing services relieving physicians to have more time to provide their esoteric medical services.

A recent article discusses selected advanced types of nurses who are eligible for Medicare reimbursement. (6). This demonstrates that America’s rank and file RN’s are excluded from Medicare’s third party reimbursement being excluded from its fee schedule, not reimbursing them for their nursing services to Medicare patients. Including our rank and file nurses in Medicare’s fee schedule for reimbursement should keep Medicare solvent which is at issue at this time.

You can practice privately as solo practitioners, in partnerships or in groups with several RN’s providing general or specialized services. Your practice could be in your home or another location. Research your laws. Your practice should be the medical model but only providing nursing services that you are licensed and competent to provide.

The medical model means your practice looks like a physician’s office with a waiting room, tables, magazines, music, rest rooms, reception area, treatment or exam rooms, with nursing supplies and equipment like bandages, alcohol swabs, solutions, sphygmomanometers, stethoscopes thermometers, gloves, exam tables, scales, garbage containers, lighting, your office, files, phones, etc. Only provide nursing services you are licensed to practice and competent in and get physician orders when needed.

Your nursing care is the same as in traditional work settings where you are licensed and registered as an RN practicing professional registered nursing as licensed. Obtain physician orders as needed, keep nursing and patient records, communicate with nurses, physicians, patients, families, laboratories, hospitals, nursing homes, other health providers and others as you do from traditional employment settings.

Recommendation is to have two years of full time traditional nursing employment or more before entering private nursing practice. Communicate with your Board of Nursing to inform them of your interest to practice this way and to glean their response first.

RN’s are originally licensed to practice nursing in their state by their Board of Nursing. They renew their original license to practice Registered Professional Nursing via a Registration with this Board. Thus RN’s maintain their original license to practice Registered Professional Nursing. Should RN’s be called Licensed Professional Nurses to raise public cognition that RN’s are licensed to practice registered professional nursing?

My opinion is that all states permit this self-employment. Some states have this written into their statutes or nurse practice acts. Many of your peers, friends and others will tell you this can’t be done for a host of reasons, they are usually not well informed or don’t know. Don’t rely on their information alone, ask your Board of Nursing, research this, seek legal advice as needed and create a business plan for your private nursing practice.

Nursing schools should have a required or elective course about this. Nurses entering private nursing practice should diminish the nursing shortage and improve our profession. RN’s practicing this way would raise nurse’s recognition, pride, satisfaction, income and recruitment into nursing. Providing nursing services to patients through your private nursing practice should be legal in all states as long as you only practice Registered Nursing where you are licensed to practice Registered Professional Nursing.

New York State passed a law mandating private health insurers that want to sell their private health insurance in NY, that they must include NY RN’s in their fee schedules for reimbursement for their nursing services. This law is:

Chapter 996, laws of 1984
Section 3221, Article 32
This is one portion of section 3221.

GROUP OR BLANKET ACCIDENT AND HEALTH INSURANCE POLICY-STANDARD PROVISIONS-CARE BY LICENSED REGISTERED PROFESSIONAL NURSE

Chapter 996

Approved December 18, 1984, effective as provided in Section 3
Passed on message of necessity. See Const. Art IX, Section 2 (b) (2), and McKinney’s Legislative Law Section 44.

An Act to amend the insurance law, in relation to registered professional nurses.
This concept of each state mandating that the private health insurers in their state quote their rank and file RN’s in their fee schedules should be adopted by all states for the succor of their patients and for the advancement of our nursing profession.

Footnotes:

  1. Four Nurses Hang Out a Shingle. American Journal of Nursing. Vol. 72, No. 10. October 1972: 1782.
  2. Beginning and Independent Nursing Practice. Betty C. Agree. American Journal of Nursing 76, no. 4. April 1974: 638.
  3. Private Practice in Nursing: Development and Management. Charles J. Koltz, Jr. Aspen Systems Corp., Germantown, MD, 1979. ISBN # 0894431587: 3
  4. New Medicare Provisions to Recognize and Pay for Core Nursing Services.
    ANA Advocated Including Care Coordination, Transitional Care in Reimbursement Policies.
    American Nurses Association, for Immediate Release, November 15, 2012: 2.
    http://www.nursingworld.org/EspeciallyForYou/AdvancedPracticeNurses/Finance-and-Reimbursement/Medicare-Recognize-Pay-for-Core-Nursing-Services.pdf
  5. Medicare commission contemplates boosting reimbursements for advanced practice registered nurses. Tuesday, April 9, 2013. http://www.enursingcareers.com/News/Detail/418960
  6. APRN’s participation as Medicare Part B Providers in 2012. Peter McMenamin. Friday, March 28, 2014, 4:35 PM. ananursespace.
    http://www.ananursespace.org/blogs/peter-mcmenamin/2014/03/28/quikstats-2012-aprns-in-medicare-part-b?ssopc=1

References:

  1. Medicare Physician Fee Schedule Final Rule (CMS). Impact on APRNs/RNs. American Nurses Association. South Carolina Nurse-January, February, March 2013: 15.
  2. New Medicare Payment Rules: Danger or Opportunity for Nursing? Ellen T. Kurtzman, MPH RN; Peter I. Buerhaus, PhD, RN, FAAN. American Journal of Nursing, June 2008, Vol. 108, No. 6: 30.
  3. Koltz, C. Private Practice for Nurses. Nursing Spectrum, January 12, 2004, New England Edition (NE): 26. nursingspectrum.com.
  4. The American Nurse. Official Newspaper of the American Nurses Association. Vol. 12, No. 1. January 1980.
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  1. This is a good article that sets out a different practice model for nurses. I do want to provide more information. Nurse Anesthetists have been part of the Medicare Part B reimbursement system since 1989 and were the first nursing specialty group to be paid directly. We do not have limited Medicare reimbursement you mentioned in the article. In fact, we get paid on parity with MD anesthesiologists for one to one anesthesia care.

    Because of the paucity of information on the business component of the CRNA profession, I am part of a group of CRNA businesspeople who are setting up a new endeavor, Anesthesia Business Academy,. We will teach CRNAs and SRNAs how to run an anesthesia business or how to negotiate a contract for services. This is so needed. Our launch date is going to be in October, 2017.–janmannino@anesthesiabusiness.com

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