THERE IS AN AGE-OLD PROBLEM when it comes to finding the cost of nursing services in a hospital bill, because nursing is buried in the room charge. We talked about this issue in the 1970’s when I became a nurse, and we are talking about it today.
This is not a subject that a few of us are talking about. This is a subject nurses at every level are talking about. You can see some of the discussion by doing a quick google search. Enter “where is nursing in the hospital bill?” and out pops myriad articles. Among the articles I found were:
- allnurses.com – Should nursing charges be separate from the room charges? (2003)
- beckershospitalreview.com: Want to Fix the Nursing Shortage? Change this 100-year-old policy (2023)
- thefreelibrary.com – Nursing is the room rate (2012)
HISTORY
“Want to Fix the Nursing Shortage?” explained how nursing got into the room charge in the first place. In the 1920-30’s, medical science expanded. More people were admitted to hospitals and the need for 24-hour nursing care also expanded. Rather than billing patients separately for nursing care, as they had done when patients paid for their own private duty nurses, hospitals rolled the cost of nursing services into the hospital bill – where nursing has stayed for nearly 100 years. Nursing has changed greatly in the past 100 years, but billing has remained the same.
History is important to know how we got where we are. Now it is time to change.
CURRENT DEBATE
What is the best system to fix this problem and show the value of the nurse? There are two systems that can function to identify the unique impact of nursing. Medicare, Medicaid, and many private insurers require the use of the National Provider Identifier (NPI) which is administered by the Centers for Medicare and Medicaid Services (CMS). NCSBN also automatically assigns every licensed nurse an NCSBN ID number in their Nursys database.
These two systems both offer different and important pieces of the puzzle. The NPI is required for clinicians like APRNs to bill for services in most cases. While RNs cannot directly bill for services at this time, they can register for an NPI. The NCSBN ID provides the aggregate data on nurses needed for research on nursing practice impact. These two identifiers can work together to change reimbursement systems to pay transparently for nurses’ care and prove how nursing practice leads to better outcomes. This information has the potential to transform how healthcare employers engage RNs, for the benefit of patients and the nursing profession.
The ANA Position is that all nurses should enroll into the NPI Registry, so that registered nurse payment could be extracted from the room charge.
ANA – NURSE PROVIDER IDENTIFIER
“ Registered nurses (RNs) are integral parts of the health care team and spend significant time with patients providing clinical services. In the current health care financing system, this work is generally not accounted for, other than in the physician’s practice expense (PE) relative value unit (RVU). The lack of NPIs for nurses makes it extremely difficult to record, measure, and value the services they provide and their impact on patient outcomes….. Obtaining and recording NPIs in appropriate healthcare data systems would allow health systems payers, and enterprise resource planing systems to extract nursing services from other providers. This then allows for a quantitative analysis and substantive demonstration of the nurse’s role and value as an integral member of a patient’s health care team.”
The NCSBN Position is that all nurses have a NCSBN identifier that uniquely identifies all nurses, which could provide aggregate data to research nursings contributions through the care continuum.
NCSBN – UNIQUE NURSE IDENTIFIER
- UNI (nurse’s NCSBN ID) allows to uniquely identify a U.S. nurse regardless of how many states in which the nurse is licensed. It is an eight-digit public identifier assigned to a nurse for life upon getter their first U.S. nurse license (LPN/LVN or RN) and will never expire or be recycled, just like SSN is to an individual.
- Federal, state, Non-profit, For-profit, Hospital systems, Educational institutions – ALL have nurse data sets for nurses in their systems and databases. With UNI embedded in their data sets, protected nurse personally identifiable information (PI) such as SSN, DOB etc. will no longer be needed for nurse identification and will facilitate data sharing and exchange for research, operational and important public protection work. UNI is publicly available; however, it is the responsibility of each organization to securely protect their nurse data sets.
- Information systems can relatively easily record nurse’s patient care contributions throughout the care continuum by simply using the UNI. Aggregate data analysis can help with meaningful evidence-based decisions. Searching for a nurse in databases can be made easy using ONLY the UNI.
ANA FREQUENTLY ASKED QUESTIONS ABOUT THE NPI
What is an NPI? NPIs are unique identifiers used by providers to bill Medicare and Medicaid for services they provide. They are currently the only identifiers allowed by the Centers for Medicaid and Medicare Services (CMS).
Why should I obtain an NPI? NPI numbers are the only numbering system currently approved for providers like APRNs to bill Medicare and Medicaid.
How do I obtain an NPI? Applications for NPIs can be found through CMS’ website: https://nppes.cms.hhs.gov/#/
Why is it important to have an NPI to track the care that nurses provide? As nurses, we know that our care is a crucial component of healthcare quality and health outcomes. Yet an RN’s time and expertise are now completely invisible to the systems that pay for patient care. As a result, the value of RN care to the system is not quantified. Nursing care should be counted! Tracking that care with an NPI is an essential first step in changing how health systems and other practitioners view nurses and the work that they do. The ultimate goal is changing healthcare reimbursement to account for the role of RN care.
What is the cost for an NPI? There is no cost to obtain and maintain an NPI.
How long do I keep my NPI? The NPI lasts throughout your professional career and travels with you from position to position. Make sure to update the NPI system when you change employers.
How do I obtain more information from ANA on NPI? To obtain more information please contact ANA’s policy team at gova@ana.org
Who administers the NPI process and why? The process is administered by CMS. Congress passed legislation requiring CMS to create a unique identifier for providers and the result of this was the NPI. CMS requires NPIs to process Medicare payments, and to support data analysis for the Medicare program.
Do private payers require NPI numbers? Most private payers require NPI numbers for billing, but it is not a legal requirement.
Does the NPI cross state lines? Yes. NPIs are nationwide and cross state lines.
I am an APRN and bill under my practice/hospital NPI, why should I get an NPI? Unless one has an NPI, it is impossible to track the work you do versus the work done by other clinicians in the practice. Additionally, if one chooses to start their own practice they would need an NPI to bill Medicare and Medicaid for reimbursement.
I am an RN and I don’t bill separately, why should I get an NPI? It is true that RNs do not currently bill, but we believe that nurses are not paid appropriately for the work they perform. There is currently no way to track all the work that nurses do to show their full value, but by registering for an NPI we can start building the data to show the impact of nurses.
Other organizations are requesting that I use my NCSBN ID. Does this conflict with an NPI? This does not conflict with ANA’s recommendation of obtaining an NPI. Key organizations using NCSBN IDs are doing important research that can also help show the value of nursing. They are using this ID as all nurses are automatically given an NCSBN ID. The NPI was developed specifically for billing and reimbursement purposes, which is an area of priority focus for ANA advocacy. Both identifiers are important to changing how systems value and reimburse nurses.
NEXT STEPS
The solution is not “either or” but “both/and”! – We need to begin the process of ensuring that all nurses have both identifiers. Since nurses are automatically enrolled in the NSCNB database, this means that we need to be encouraging all nurses to enroll in the NPI at https://nppes.cms.hhs.gov/#/, It is free and easy to do. It’s the first step in making sure our history does not become our future. It is time to fully show the value of nursing.
REFERENCES:
An Overview and Policy Implications of national nurse identifier systems: A Call for unity and integration https://www.nursingoutlook.org/article/S0029-6554(22)00180-4/fulltext
A Unique Identifier: Frequently Asked Questions (FAQ) https://www.allianceni.org/sites/allianceni/files/wysiwyg/inline-documents/Unique_Nurse_ID_FAQ_Final.pdf
NPI: What You Need to Know https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/NPI-What-You-Need-To-Know.pdf
Position Statement: National Patient Identifier (NPI) as Nurse Identifier https://www.nursingworld.org/~493c6b/globalassets/practiceandpolicy/nursing-excellence/ana-position-statements/nursing-practice/npi-position-statement.pdf
Want to fix the nursing shortage? Change this 100-year-old policy https://www.beckershospitalreview.com/want-to-fix-the-nursing-shortage-change-this-100-year-old-policy.html
