Ask a Lawyer: Nurse Practitioner Billing

Question:

I am a nurse practitioner (NP) and am considering accepting a position working in a medical clinic. The contract for my services specifies that I will be compensated based on my billing to the public health insurance plan. I am aware that physicians are authorized to directly bill public health insurance plans, but is it permissible for NPs to do so?

Answer: 

To date, no province or territory has assigned NPs individual billing numbers for them to directly bill any public health insurance plan for the insured health services they provide to their patients. This means that the compensation framework for health services provided by physicians and NPs is fundamentally different. Physicians are typically compensated through a fee-for-service model whereby they directly bill the patient’s public health insurance plan for rendered insured health services. As a result, most NPs are paid on a salary basis. NPs may also work as independent contractors and bill patients directly for health services, insured or otherwise. It would be prudent to be aware of any billing restrictions in your province or territory that may be applicable when negotiating compensation with your employer or workplace.

Some jurisdictions have allocated identification numbers to nurse practitioners under the relevant public health insurance plan for purposes other than payment. For example, all licensed NPs in British Columbia are required to enrol with the Medical Services Plan/Health Insurance BC and obtain a practitioner number. The practitioner number permits the NP to submit encounter records for insured services provided to patients who are registered under the Plan, refer clients to other medical practitioners and health professionals, and order laboratory or diagnostic tests.¹ However, these practitioner numbers are not used for compensation purposes, but rather to capture nurse practitioner practice activities.

It is also important to note that physicians may appropriately bill the public health insurance plans for consulting or being involved at some point in the assessment of a patient who is otherwise being treated by an NP. Billing schedules often provide that billing the public health insurance plan is not permitted if a physician is not involved in the provision of the services.

In a recent decision, an NP working at a medical clinic was directed by the physicians he worked with to bill the public insurance plan using the physicians’ unique identifiers. The NP was assured that this was acceptable. When he learned that this information was incorrect, he ceased employment at the medical clinic. Nonetheless, a finding of professional misconduct was made against the NP as there was no physician involvement in the provision of the billed services. The NP was required, among other things, to pay a fine and costs, complete educational courses, and have a summary of the disposition appear on the public register.²

In another case, the Manitoba College of Physicians and Surgeons Disciplinary Committee investigated a physician for inappropriately submitting claims to Manitoba Health. The Committee found that over a two-year period, the physician had been billing Manitoba Health in his own name for house visits conducted by an NP at his clinic. The physician initially stated that he was able to do this because there was always a live video feed with house visits through which he could supervise, and he always signed off on the NP’s EMR documentation of the visits. After the investigation, the physician recanted his initial statement and admitted that there was not always a live video feed, and that he did not review the NP’s records. For inappropriately billing Manitoba Health and misleading the College, the physician was reprimanded, had his license suspended for five months, and was required to pay the costs of the investigation.³

CNPS beneficiaries can contact CNPS at 1-800-267-3390 to speak with a member of CNPS legal counsel. All calls are confidential.

1. British Columbia Ministry of Health, “Nurse Practitioner Enrollment in the Medical Services Plan/Health Insurance BC,” 2017.
2. Decision of the College of Registered Nurses of Manitoba Discipline Committee in action between the College of Registered Nurses of Manitoba and CRNM Member #138111. June 23, 2016.
3. Kloppers (Re), 2014 CanLII 56884 (MB CPSDC), <https://canlii.ca/t/gds29>

Published May 2016, Revised November 2024

THIS PUBLICATION IS FOR INFORMATION PURPOSES ONLY. NOTHING IN THIS PUBLICATION SHOULD BE CONSTRUED AS LEGAL ADVICE FROM ANY LAWYER, CONTRIBUTOR OR THE CNPS. READERS SHOULD CONSULT LEGAL COUNSEL FOR SPECIFIC ADVICE.