Laws pertaining to third-party reimbursement of RN first assistants - registered nurses

AORN Journal, July, 2001 by Frederick P. Franko

AORN members continue to express interest in reimbursement legislation for services performed by RN first assistants (RNFAs). With the exception of Medicare, reimbursement is a state issue, thus it requires legislative action at the state level.

Reimbursement for surgical first assisting services performed by RNFAs is one of AORN's legislative priorities determined by the AORN Board of Directors. At the federal level, the effort is focused on HR 822, the "Medicare Certified Registered Nurse First Assistant Direct Reimbursement Act of 2001," introduced by Rep Mac Collins (R-Ga). This bill would provide Medicare reimbursement for surgical first assisting services for certified RNFAs at 13.6% of the surgeon's fee. At the state level, AORN members are developing proposals to amend state statutes for reimbursement by Medicaid, managed health care agencies, workers' compensation carriers, and private third-party payers.

Each state has its own laws and regulations that AORN members must know before pursuing RNFA reimbursement legislation. All states recognize that first assisting is within the scope of professional practice of RNs. The issue, therefore, is whether an RNFA receives reimbursement from Medicaid, managed health care agencies, workers' compensation carriers, or private third-party insurers.

Currently, eight states have laws or regulations pertaining to third-party reimbursement of RNFAs. Seven other states introduced such legislation earlier this year. In each state, legislation is tailored to meet the needs of the state's RNFAs and the state's legal requirements and political reality. An important legal concern when drafting RNFA reimbursement legislation is whether state statutes address reimbursement for services or for providers. Legislation should be designed according to the laws of each state.

When developing legislative language, it is necessary to identify all statutes governing reimbursement for services or providers and make appropriate changes pertaining to Medicaid, workers' compensation, all state agencies from which reimbursement is desired, and the state's insurance code. Following is a brief overview of the laws currently in effect.

FLORIDA

In 1994, the Florida legislature added a new section to the Florida statutes to define perioperative nursing, recognize RNFA programs, and identify qualifications for RNFAs. The law pertaining to reimbursement states

   Notwithstanding any other provision of law, when any health insurance
   policy, health care services plan, or other contract provides for payment
   for surgical first assisting benefits or services, the policy, plan, or
   contract is to be construed as providing for payment to a registered nurse
   first assistant who performs such services that are within the scope of a
   registered nurse first assistant's professional license.(1)

Medicaid reimbursement was added to the Florida statutes in 1997. This law allows the Florida Agency for Health Care Administration to pay for RNFA services. Although the law does not outline required RNFA education or experience or provide a definition of RNFAs, the law does specify RNFAs as providers.

This law mandates that the Florida agency may pay for all services provided to a recipient by an RNFA as described in Florida statute [sections] 464.027. Reimbursement for such services may not be less than 80% of the reimbursement that would be paid to a physician providing the same services.(2)

Title XXXII, Regulation of Professions and Occupations, Chapter 464, [sections] 464.027 (1)(b), Registered Nurse First Assistant, of the Florida statute now states

   provide for reimbursement for the registered nurse first assistant from
   managed health care agencies, state agencies, workers' compensation
   carriers, and private insurance companies.(3)

GEORGIA

A Georgia law enacted in 2001 establishes policies to provide reimbursement by managed health care agencies, workers' compensation carriers, and private third-party insurers, and for services provided by RNFAs. This law does not include reimbursement for Medicaid or any other publicly funded state health care program. Supporters plan to introduce new legislation next year to include Medicaid.

Section 33-24-59.9(b)(2) of this law establishes policies within managed health care agencies, workers' compensation carriers, and all private third-party insurers, to provide for adequate and justifiable reimbursement of RNFAs for services rendered. The law includes the following definitions and minimum education qualifications to help define RNFAs.

   (c)(3) "Perioperative nursing" means a practice of registered professional
   nursing in which the registered nurse provides preoperative,
   intraoperative, and postoperative nursing care to surgical patients. (4)
   "Recognized educational curriculum program" means a program that: (A)
   Addresses all content of the Association of periOperative Registered
   Nurses, Inc, Core Curriculum for the Registered Nurse First Assistant and
   the Certification Board of Perioperative Nurses; and includes indicated
   didactic and clinical internship as required by the curriculum.(4)