Advanced Practice Providers: An Opportunity to Address Lengthy Appointment Waits

Researchers are finally supporting what you already experience every day in your medical practice – there is an overwhelming amount of patient demand. According to a national data repository, visits are up 14% over 2019’s pre-pandemic baseline. This fact, in combination  with mounting evidence of an impending physician shortage, has medical practices increasingly evaluating the opportunity to integrate or expand the utilization of advanced practice providers (APPs).  This category of clinicians includes physician assistants (PA), nurse practitioners (NP), certified nurse midwives (CNM) and certified registered nurse anesthetists (CRNA). As demand for their services has grown, the cost of recruiting, hiring, and retaining APPs has also increased. Therefore, intentionality about their use in your practice is vital. If employing an APP is in your future, these factors may be under consideration:

Ditch ‘incident to’? Historically, medical practices used a specific protocol to bill for the services of advanced practice providers. A Medicare term, “incident to”, translates into billing for the APP’s services under a physician’s name/NPI in the outpatient setting. The billing physician is typically the supervising physician or another physician in the same practice, who may not interact with the patient for the encounter. There is an extensive set of requirements to bill ‘incident to’, and most commercial insurers have adopted this Medicare concept. There are, however, nuances that differ between insurers (including Medicare Administrative Contractors), and the rules are constantly changing. Appropriately complying with current requirements, therefore, requires a heavy lift for the practice, with no room for error. In turn, the practice receives 100% of the physician fee schedule when billing ‘incident to’. However, many practices are migrating away from this once-preferred billing method. Why? Insurers are recognizing APPs as billing professionals (with some insurers even agreeing to pay the higher physician rate). With the shift to value-based payments, direct billing by the APP allows insurers to monitor the quality of care the APP provides using their quality indicators.  Further, there is evidence that relieving the practice of the burden of the requirements may translate into higher productivity.

Refine the pitch. The words that staff use when referring to APPs are crucial. Consider the patient’s perspective during a phone call to schedule an appointment under these two scenarios:

Dr. Famous is busy until later this spring, but there is a midlevel available. Her name is Judy, and she can see you next week. Would you like to schedule your appointment with the physician extender?

Dr. Famous has appointments available later this spring, however, a member of Dr. Famous’ care team has an opening next week if you’d like the team’s first available appointment. Judy Garcia is a certified physician assistant, and I can get you in with Ms. Garcia next week. Would you like to schedule your appointment with Judy Garcia?

Many patients would take advantage of the second scenario, while most (not surprisingly) would refuse the first. There is no industry standard for the script; however, practices are moving away from the descriptors, “non-physician,” “midlevel,” and “extender,” as they may have a negative connotation for some patients (and providers). Further, references to the clinician as being possessed or owned by a physician are also migrating out of our lexicon. The terms are being replaced by the clinician’s name and credential and/or the collective term, advanced practice provider. (It is important to comply with any Title Transparency laws in your state.) Although references by staff are important, the most important stakeholders for the refined script are the physicians. If you don’t believe that your advanced practice provider is a valuable member of your team, your patients are going to sense that – and avoid seeing them. On the flip side, your encouragement can make a huge difference.

Understand the role. Medical practices hire advanced practice providers for a multitude of reasons. APPs may focus on post-operative visits exclusively, for example. Practices are considering novel ways to deploy advanced practice providers because of the ever-increasing disparity between supply and demand. For example, a neurology practice may employ an APP to manage patients with Parkinson’s and support their caregivers (caregiver training is now billable for select insurances, including Medicare), under the direction of the neurologist. Or the practice may offer same-day/next-day rapid-access appointments for patients, managed by the APP. Other approaches include messaging and/or telemedicine visits, both billable for Medicare and many other insurers. Finally, APPs are increasingly being used for new patient encounters, with the goal of assessing the patient, determining and arranging for diagnostics, and engaging with the patient and family. Importantly, these decisions are impacted by the physicians’ support of the role, as applicable; the professional’s scope of practice; and the relevant state regulations.

Consider this new resource if you’re evaluating the role of APPs in your practice.

Advanced practice providers may not be able to fully solve the supply and demand imbalance in your practice, however, they may be able to help. It’s an opportune time to consider the role of an advanced practice provider in your practice.