Clash over AMA petition to tighten regulations for advanced practice nurses

Turf war
Clash over AMA petition to tighten regulations for advanced practice nurses

By Jennifer Birch
November 20, 2000
Photo: Photodisc

The American Medical Association has submitted a "citizens petition" to the Health Care Financing Administration. The premise of the document is that HCFA needs to protect the public from NPs or other health care providers who might pose a risk by overstepping their scope of practice.


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More than four months have passed since the American Medical Association submitted a "citizens’ petition" to the Health Care Financing Administration, the federal agency responsible for administering Medicare and Medicaid. The petition accuses the administration of failure to uphold existing regulations and laws concerning Medicare Part B payments that govern nurse practitioners and clinical nurse specialists.

The petition
Signed by 49 medical specialty organizations, the petition charges that HCFA "has failed to uphold the intent of Congress and its duty to taxpayers and Medicare beneficiaries by encouraging advanced practice registered nurses to practice beyond legally authorized safeguards."

The petition, which has yet to be addressed by HCFA, calls for four specific steps:

Implement "a system to ensure that Medicare payments to NPs and clinical nurse specialists are made only in connection with those services furnished in collaboration with a physician and within their state law’s scope of practice requirements."
Limit distribution and renewal of Medicare billing numbers only to those NPs and clinical nurse specialists who comply with the collaboration and state law scope of practice requirements.
Issue detailed instructions to Medicare carriers on implementation of a system to ensure compliance with the collaboration and state law scope of practice requirements.
Audit practice or hospital sites of NPs and clinical nurse specialists now and periodically thereafter to "ensure that Medicare payments to NPs and clinical nurse specialists are limited to services furnished in collaboration with a physician and within their state law scope of practice requirements."

The premise of the document is that HCFA needs to protect the public from NPs or other health care providers who might pose a risk by overstepping their scope of practice. Robert Mills, AMA public information officer, said that the intent of the petition is an effort to prevent HCFA from paying providers who may be practicing beyond their area of expertise.

Nurses respond
In response, the American Nurses Association submitted a letter to HCFA, signed by more than 200 nursing groups, stating that "the ANA does not believe that the steps proposed in the AMA Citizens’ Petition are necessary or appropriate. The attempt to redefine existing reimbursement rules and to intensify scrutiny by HCFA of Part B services provided by NPs and clinical nurse specialists to Medicare beneficiaries will create additional barriers to the full scope of practice of APRNs. These barriers could have a chilling effect on their reimbursement opportunities and will significantly reduce Medicare beneficiaries’ access to safe, appropriate, quality health care services."

American Association of Critical-Care Nurses spokeswoman Janice Weber, MSN, RN, said, "We endorsed the letter the ANA spearheaded. That is our official statement. I would be hesitant to comment on their [AMA’s] motivations."

Jan Towers, Ph.D., NP, director of the Health Policy Office at the American Academy of Nurse Practitioners, said, "No more response is needed at this point; they are not going to find any irregularities and there is no reason for them [AMA] to suppose that people are saying they’re licensed who aren’t, or are billing without following guidelines. The bottom line is HCFA is answerable to Congress."

"It’s a rather unusual stance for the physicians to take to attack the nurses. There are already plenty of safeguards in place for HCFA to have oversight on the way advanced practice nurses are going to bill and the way we have been billing – and nobody has complained. AMA can put all the petitions they want out there, but we’re not the problem," said certified nurse-midwife Marion McCartney, director of professional services at the American College of Nurse-Midwives in Washington.

Analysis provided through the American College of Nurse Practitioners concludes that "there is simply no data to suggest that NPs either practice beyond their scope of practice or inappropriately bill for their services. Thus, it is unclear why NPs should be burdened by additional oversight or audit requirements that other Part B providers, such as physicians, are not."

Contradictions
The same week that the petition was delivered, AMA representative Yank Coble, MD, appeared on Capitol Hill to testify before the House Committee on Commerce Subcommittee on Health and Environment. He expressed the AMA’s concerns about the already existing amounts of HCFA red tape and said, "Health care is a highly regulated profession, and HCFA is overzealous in its regulatory scope and enforcement activities."

Some nursing groups believe the AMA’s open criticism that HCFA overregulates health care is evidence that the AMA’s earlier petition was motivated by something other than concern for the public.

"As far as I can see," McCartney said, "they [AMA] base it on nothing. They’re just so threatened by nurses doing anything that has been traditionally medicine, and whether we do a good job or not, they are going to be opposed to it, including getting paid, which is most threatening to them. As soon as the payment is going directly into the nurses’ pockets, that’s threatening."

HCFA had no comment as to when or how the agency would respond to the petition.