When nurse practitioner Mary Lou Hendrix opened her own high-risk-pregnancy practice in Evergreen and Cherry Creek last spring after more than 25 years of providing such care in physicians’ offices, she was well-prepared for the medical challenges she would face.
But she was not ready for the still-unresolved nightmare of trying to get recognized and reimbursed by insurance companies.
A dozen companies that had covered her services as long as she was working under a physician either turned her down, saying they don’t credential solo nurse practitioners, or stalled in maddening ways her applications for credentialing. She has been working nearly for free for seven months to provide care for her patients.
This is happening to advanced-practice nurses in solo practices across Colorado despite a 2008 state law that specifies nurse practitioners do not need to work under the auspices of a physician to be credentialed and reimbursed by insurance companies. State law also requires that these advanced nurses be reimbursed the same as physicians for providing identical services.
“This is a huge issue in health care reform,” said Fran Ricker, director of the Colorado Nurses Association. “It’s an issue that is going to be less about how many health care providers are in Colorado and more on how they are credentialed.”
Credentialing is the term for the process that medical providers must undergo to contract with individual insurance companies for reimbursement. Providers apply for credentials and are checked out to determine if they are legitimate and if their services are needed in a given area. Providers are supposed to get a rejection or approval within 60 to 90 days.
Insurance companies contacted by The Denver Post either did not return calls or declined to comment, directing calls to their trade organization.
Ben Price, director of the Association of Health Plans, said his group is looking at the issue and “trying to pull a meeting together with members.”
Tales of insurance woes
For advanced-practice nurses, who have varying levels of postgraduate education, clinical experience and certification, tales of insurance woes echo with the same details.
In Hendrix’s case, only one insurance company, United HealthCare, credentialed her with no hassle and no extra wait. Medicare and Medicaid also credentialed her for government reimbursement.
She said that when she called half a dozen other companies to find out if her credentialing was complete, she was told her application had been “lost” or had some clerical problem. Numerous times, the months-long process began all over again.
“It was just delays and delays and delays,” said Hendrix, who is the only certified provider for high-risk-pregnancy care between C-470 and Breckenridge.
The nurses association recently met to hash over the issue with the Colorado Division of Insurance and the Association of Health Plans, the trade group that represents Colorado insurance companies. There was no immediate resolution to the problem.
“It was a very good meeting, and we agreed to go back to our members and get their input,” Price said.
Dr. Michael Pramenko, president of the Colorado Medical Society, calls it “a really tough issue.”
He acknowledges the need for advanced-practice nurses to fill gaps in primary care but thinks they need to work under the auspices of physicians, perhaps through a digital collaboration with the physician in another location.
“If we reimburse nurse practitioners independently, why is there a need for medical school in the future? We need to make sure we continue to have highly trained physicians,” Pramenko said.
Much of the same care
Colorado’s 4,230 licensed advanced-practice nurses are allowed to do much of the care provided by primary-care physicians. They can prescribe medications after several years of prescription supervision by physicians. They can handle any problems that might show up in a doctor’s office, except they’re not allowed to treat cardiac irregularities, do surgeries or deal with neurological problems.
Kathy Gutierrez, who has been practicing under physicians in the Denver area since 1995, recently opened a new clinic in Lakewood. She chose that area because she was seeing so many patients going without primary care. Many physicians’ offices would not accept Medicare and Medicaid patients.
Gutierrez was turned down for credentialing by three companies and was told that another primary-care practice was not needed in Jefferson County.
“It’s frustrating, but we will continue to work on it and keep pressing the insurance companies until they see the error of their ways,” said Gutierrez, who has written nursing textbooks and overseen the clinical education of medical students.
Linda Pearson, a psychiatric nurse practitioner in Denver, has compiled national research on nurse practitioners that shows many states have similar legal or insurance ambivalence about nurse practitioners.
She said part of the issue in Colorado might be that the law is so new that insurers are “still coming around.”
While they come around, Hendrix had waited about as long as she is able. Last week she got some relief from a number of insurance companies after she called and told them she had been talking about the issue with a Denver Post reporter.
Two of the companies that had been stalling for months — and refusing to give her any reasons in writing — all of a sudden approved her credentials. Others gave her dates when she could expect to begin submitting her bills for payment.
“But I fear they are making an exception for me,” Hendrix said. “There are a lot more coming after me, so this problem isn’t over.”
Nancy Lofholm: 970-256-1957 or nlofholm@denverpost.com
