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: 

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. To date, no province or territory has assigned NPs individual billing numbers in order for them to directly bill any public health insurance plan for the insured health services they provide to their patients. As a result, NPs are usually paid on a salary basis.

In some jurisdictions, nurse practitioners have been allocated identification numbers 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 (“the Plan”) 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. 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 where the physician has no involvement in the provision of the services, billing the public health insurance plan is not permitted.

In the case at hand, the NP will need to negotiate a solution with the clinic for the compensation of their services. When negotiating this solution, it would be prudent for the NP to be aware of any billing restrictions in their province or territory applicable to the services provided by NPs.

In a recent decision, an NP working at a medical clinic was directed by the physicians he worked with to bill the 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.1

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

1.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.

Published May 2016, Revised July 2016

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.