An RN first assistant's guide to private practice - registered nurse

AORN Journal,  April, 2003  by Sheila Hughes

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MANAGED CARE ORGANIZATIONS

Prepaid health plans are called managed care organizations. The general models of managed care organizations include health maintenance organizations, preferred provider organizations, and integrated delivery systems. (25) The distinguishing factor among these models for health care providers is the way they are reimbursed.

Managed care organizations provide opportunities, challenges, and potential threats for nursing. The goal of these organizations (ie, to manage the use of appropriate health services by individual members) is consistent with the basic philosophy of nursing, which focuses on the total needs of an individual, not just on a disease. (26) In addition to providing high-quality, cost-effective health care, nurses' functions and activities in managed care can overlap or be interdependent. Nurses function as providers of services, case managers, patient advocates, patient educators, resource managers, risk managers, and liaisons. (27) All RNFAs, therefore, need to be familiar with health care legislation, propose alternatives for change, and actively engage in meaningful dialogue about the implementation of legislative reform. It is estimated that managed care organizations will handle 90% of all medical bills in this millennium; (28) therefore, using RNFAs as primary assistants in surgery is paramount for controlling costs.

RNFA REIMBURSEMENT

Registered nurse first assistant entrepreneurs should base the decision to charge for services according to the conditions of the practice with reference to travel; caseload; preoperative, intraoperative, and postoperative responsibilities and activities; weekends; call; and billing procedures. Decisions for establishing charges are based primarily on the conditions that exist for third-party reimbursement or direct billing to the surgeon. Consider the methods health care facilities use to pay providers, and select the best method or methods of compensation for each surgeon's practice or facility. In other words, RNFAs can adjust compensation to a percentage of the amount the surgeon receives from the insurance company.

There are three methods of reimbursement worth considering. First is fee-for-service, which may be the best choice if intraoperative assisting is the only service provided. Second is episode of care, which is based on a percentage of the primary surgeon's fee and would be ideal when RNFAs provide preoperative, intraoperative, and postoperative services. Third is capitation, which compensates a fixed amount at predetermined intervals, such as monthly, quarterly, semiannually, or annually. Capitation is a good choice when comprehensive or selected services are provided by RNFAs within managed care organizations. Remember that the entrepreneur is responsible for paying quarterly taxes; the surgeon or facility will provide a 1099 form for reporting income at the end of the tax year.

Billing for RNFA services is complex. Registered nurse first assistants must understand the different .types of payers and be familiar with the Current Procedural Terminology (CPT) and the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD 9 CM) codes. The CPT modifier -80 is the modifier RNFAs should use to denote that they participated in a procedure as a surgical assistant. Refer to the CPT and ICD 9 CM manuals and current books on billing for more comprehensive information, or consider taking a class. (29) Remember that codes change regularly, so be sure to use a current reference.