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Dear NNPEN Colleague and Friend: Our comments back to CMS Scope of Practice both 1) congratulates the Trump Administration for putting Full Practice Authority at stage center, recognizing it as the bipartisan issue it is; and 2) suggests ways CMS can uniquely contribute to value-based payment reform for advanced practitioners by encouraging advanced practitioners to accept the challenge of becoming informed risk-takers. Happy reading to start out 2020!
Re: Scope of Practice response to a request for feedback from CMS regarding President Trump’s Executive Order 10/3/2019
January 16, 2020
Ladies and Gentlemen of the Patients Over Paperwork Initiative:
#1—Preserve/extend the cost and quality benefits of the Nursing Process
#2—Full Practice Authority (aka Independent Scope of Practice) will generate a much-needed NP primary care outcomes database
#3--Without NPs delivering primary care access across the nation, CMS will fail to meet its Triple Aim Goals
Armed with EO #13890, CMS has the power and gravitas with a top- of -license SOP vision to overcome the payer resistance and physician stonewalling that still confounds SOP progress in more than half of our 50 states. The marketplace and the workforce are ready for SOP change that is refreshingly bipartisan. The timing of EO #13890 couldn’t be better!
We applaud President Trump and CMS for moving SOP to center-stage and look forward to working with CMS as it is rolled out. Please let us know if NNPEN can be of any assistance.
On behalf of our NP entrepreneur membership and an America filled with consumers without access to primary care, NNPEN thanks you for our opportunity to comment on SOP today.
/s/Sandy Berkowitz, RN, JD
Welcome to our new ‘hood! As NNPEN grows members, we are getting more requests for direct member-to-member interaction capabilities. This new website has been designed with that capability as one of our satisfaction metrics: demonstrate material growth in member-to-member direct interaction. Now the Blog, the Forum (discussion board) and the Membership Directory are 3 website tools NNPEN offers to support peer- to-peer dialogue with no “mother may I?’ tollgate. The key here is that these tools aim to support NNPEN members. Are you a member? If not, ask yourself: is becoming part of something bigger than you -- a growing NP entrepreneur advocacy network -- worth $144/year?
Your call to action is to try these tools out and give us feedback. Oh, and if you can’t access the forum and directory because you’re not a member, Join NNPEN today!
Many more things to talk about in 2020: a co-hosted Home-Based Primary Care Blueprint for Success conference in Phoenix in February and NNPEN’s Value-Based Payments survey, for instance. Get there in good health!
s/s Sandy Berkowitz
Co-Founder and CEO
Back in my February 2019 blog to NNPEN’s members and friends, I introduced the question: “What’s ahead for the NP-owned practice?” At the time, I strongly suggested that small NP-owned practices may reach a certain revenue threshold and plateau. The small NP practice, as an economic buyer, does not have the fiscal clout to, for example, negotiate performance-based adjustments to the payer’s stingy FFS fee schedule. By aggregating NP-owned practices into a single signature contracting entity, NPs create critical mass and economic value. So, my No. 1 takeaway for indie NPs is the need to join a contracting entity that creates clout through aggregating practices – without NP practice owners losing control of their practices or brand. “Aggregate” is my fancy way of saying GO BIG.
Then, in June 2019, I blogged about why NNPEN has begun offering business services through partnerships with PRMS for revenue cycle management (RCM) and SBSC for credentialing. In short, we see NP practices needlessly leaving 20-30% of their collectibles on the table, most notably by letting claim denials go unchallenged due to lack of time or confidence – most likely both. NNPEN encourages NP practice owners to spend their time with patients, where there is reimbursable value – and outsource RCM and credentialing.
Now it’s September, and we invite NP practice owners to kick the tires on our recently formalized partnership with the American Advanced Practice Network (American-APN) and CareSpan. We three partners aim to accelerate a nurse practitioner’s ability to establish and operate a sustainable independent clinical practice! Read our official press release announcing the partnership on CareSpan’s website.
We know that NP practice owners want to:
Being part of something bigger can mean being part of a professional community that offers evidence-based practice guidelines, peer review and emotional support, as well as the capacity to offload backroom activities that interfere with patient care time. But it can also mean bulking up to a size that third parties – read payers – cannot ignore. From NNPEN’s perspective, that is the long-term play here we find irresistible.
An important NNPEN undertaking in this partnership is to identify nurse-led practices who 1) are new to independent practice and whose collectibles goals at 24 months exceed $100,000; or 2) are established owners but have growth aspirations that are not translating into collectible revenue. For these growth- oriented practices, American-ANP/CareSpan offer important options to explore, especially before investing or reinvesting in an EMR. An NP practice owner should be asking these questions:
American-APN/CareSpan is probably not an option for an NP practice satisfied seeing fewer than 10 patients a day. Nor is it the right choice if you are not planning to add a virtual practice (telemedicine) component to your repertoire. But NNPEN sees positive work/life balance relief, managed care contracting leverage, and other economies of scale in this first creation of an NP network, and NPs need practice management choices for NP-led practices.
Information is power. NNPEN is dedicated to informing NP practice owners about emerging practice management choices. We already offer ala carte options – specifically for stand-alone revenue cycle management and credentialing – but none of these get at NPs’ needs for a network that creates critical mass in negotiations with payers. American-APN/CareSpan does.
This is a call to action for NP practice owners: Get Big! Contact us: firstname.lastname@example.org.
I’m hoping you’ve been on NNPEN’s website recently and found our new menu tab: Business Services. But maybe you haven’t. In any event, NNPEN wants you to know why we are moving into this space, and the role we think NNPEN can play to make practice start-up easier.
Like every good business owner, you want to ensure your practice is running as smoothly and efficiently as possible. However, with the numerous requirements and nuances they don’t teach you in nursing school, it can seem daunting to run a successful business on top of providing top-notch care.
NP business owners need to rely on trusted third parties to remain compliant and keep the doors open. NNPEN has identified two areas where a small investment in outsourcing will yield big dividends on your part: revenue cycle management (aka billing and collections) and credentialing.
Revenue Cycle Management
Because so many dollars and hours are at stake, revenue cycle management (RCM) is a priority for NP practice owners to investigate outsourcing. RCM’s aim is to maximize your reimbursement revenue. One stage in RCM where NP practice owners fall short is challenging claim denials; they’re not what NPs know, they can require aggressive moves, and they take time.
NNPEN partners with PRMS, a firm that is particularly comfortable challenging insurer denials because their medical record professionals are grounded in the patient’s medical record. We like this sweet spot: the industry estimates that between delays in hiring providers due to protracted credentialing timelines and the failure of providers to challenge claim denials, 30% of your gross collectable revenue is conceded to insurers here. This is money from your pocket just going free! Don’t be penny-wise and pound foolish; face up to the money you are leaving on the table!
Credentialing is important to understand but not to do yourself because the rules are arcane. Even small oversights/errors in the application process means the insurer will send your application back to square one. The longer the credentialing and contracting process takes, the longer it will take you to start generating revenue, whether it be for your services or for a new NP you want to hire. A credentialing service will track your application from beginning to end so that the needed badgering is done without sucking the energy out of your practice.
NNPEN’s partnership with nurse-owned credentialing service SBSC negotiated a material discount for a la carte credentialing services, priced at a $295 one-time provider set-up fee plus a $100 -per- application fee. Assuming you manage five applications through this system, $800 is the cradle-to-grave credentialing services cost that the NP needs to weigh against the value of her or his time.
What’s NNPEN’s Role?
NNPEN is not employing professionals with specific business services expertise, such as SBSC and PRMS. Our business model is that we find the best thoroughbreds and invite them into our stable as independent contractors. We are air traffic controllers with respect to their service delivery to you. We envision that we are a concierge service for you to find the right fit between vendors and you, and to be your mouthpiece when things go awry.
This business model of concierge services is not unique to NNPEN, but we embrace it – both because in our view it’s the right way to run our business and because it passes our smell test as a way NNPEN can earn the revenue we need to grow while furthering the business sustainability goals of our clients.
Next post will focus on the most developed business services NNPEN offers: Consulting with the Founders. WHAT we four gals know is valuable, and WHO we know is priceless. Need to know more right now? Contact us at email@example.com.
On Feb. 2, 2019, NNPEN hosted a half-day conference in Columbia, MD, titled Innovative Business Models for NP Practice: Do It Your Way! as an introduction to CareSpan, a digital healthcare platform, and AAPN, a CareSpan-aligned NP Group Practice Without Walls (GPWW). AAPN is the first NP-owned professional LLC to aggregate NP practices and negotiate NP managed care contracts as a single taxpayer identification number (TIN).
AAPN, the NP-owned PLLC, is the logical product of familiar forces converging in our healthcare marketplace:
The Feb. 2 room was filled—nearly 80 registrants, wow! That tells us NP entrepreneurs are still looking for an ownership model that works for them. CareSpan’s Integrated Network, including AAPN, may be that model. It offers indie NPs access to a basket of business support services, including access to better managed care contracts because AAPN aggregates NP practices under a single TIN to create negotiation leverage.
From our Feb. 2 speakers JoEllen Koerner (CareSpan CNO) and Kate Fiandt (AAPN CEO), I enclose a link to AAPN, which outlines what the next steps would be to evaluate your practice future as part of AAPN. This assessment has value whether you go forward with AAPN or not. Right now, AAPN is focused on attracting established NP practices with established revenues—so that there is cash flow ballast to enable onboarding newbie practices without developed revenues.
A point made by many of our speakers is that AAPN is not for everyone. (For example, if you do not foresee virtual practice as part of your business plan, this practice model may not be for you.)
But this much is true: Some NP practice aggregator alignment will be in your future; that’s how NPs will create contract leverage. AAPN/CSIN is the first (but not the last) NP-focused aggregator for you to consider. For their foresight, we applaud them. NNPEN’s role here (we think) is to encourage the growth of additional aggregator options for you and be right there with you to evaluate the fit as you consider this question: What’s Ahead For My Practice?
Are we on the right track? Say it by joining us at www.NNPEN.org.
WHY NP PRACTICES NEED “VALUE AGGREGATORS”: LET’S TALK MONEY
NP practice owners are entrepreneurs who want to be independent—to be free-standing. But best case, these independents will each see 1500 patients, and a 1500 patient panel is too small to create contracting leverage, even with remarkable outcomes that are reliably great. But if 10 NP practices, each with 1500 patient panel, combine their quality data, 15,000 lives begins to have credibility. Who collects the data and leverages these 10 NP practices’ outcomes into some share of the savings flowing to the NPs? Who supports the business end of the 10 practices so the NPs can do what they love? Below I propose the not-so-new idea of a value aggregator as the entity that brings the necessary capabilities to the table to give those 10 practices “the independence they want and the support that they need”. What will success of an NP value aggregator look like? I vote for negotiation of payment models that leverage the quality and cost value the nursing process invariably produces.
At NNPEN’s second annual conference, Minneapolis 2018, we saw an independent (indie) NP practice profile developing: maybe no brick and mortar office space, outsourced backroom functions, digital clinical platform, and miserly (even in FPA states) commercial insurer payments, based on an unsustaining Fee For Service schedule at 85% of Medicare’s Physician rate. And adding insult to injury, payments offered no opportunity to boost the NP practice’s FFS revenue base with either or both of two enhancements health insurers offer every primary care physician: 1) care coordination fees and 2) shared savings (SS) programs that encourage the provider to benefit from better than average quality of outcomes and cost-effectiveness. The economic implications of this for a small 1 FTE NP practice with a patient panel of 1500, are not chopped liver. Modeling done for NNPEN for our Summer 2018 NPE Conference conservatively estimates a Shared Savings impact of $9,000 annually for our hypothetical 1 FTE NP practice.
How do nurse-owned practices negotiate for these fairly modest concessions—essentially, a leveling of the reimbursement playing field? Bring numbers to the table! # of PCPs, # of patients, a depth and breadth of coherent data detail. Aggregation generates value. NNPEN’s position is that payment reform requires NPs looking beyond their individual practices to imagine what being part of a “single signature” contracting entity—an “aggregator”– might look like. Is it a PC? Is it an IPA? Is it a Management Services Organization (MSO)? Is it owned by the providers themselves? Does it offer a solution to the business acumen deficit most practice owners experience and, as noted earlier, want to outsource to a trusted MSO?
We see both national and local solutions emerging here. Fortunately, the first “single signature” contracting entity opportunity for indie NP practices –the first “value aggregator”– is at our doorstep: CareSpan, a digital healthcare company. .
NNPEN wants to be right there with our members in evaluating the fit between aggregators like CareSpan and independent NP practices. SO: over the next few months NNPEN is scheduling live sessions with CareSpan and interested NP Entrepreneurs: the first will be in Baltimore, MD area in the first quarter of 2019—Saturday February 2, 2019 1:00pm to 4:30pm, to be exact. Program information coming soon.
There was a lot of re-imagining to be had at the 2018 Midwest Region Dual Track NP Entrepreneurship Conference in Minneapolis. For one thing, we 4Mothers (Lynn, Lorraine, Beth and me) are beginning to think of NNPEN as industry “Conveners” and we like the way that fits us! And I have some conference takeaways on the content side that challenge our vision of the future.
I moderated a Rural/Urban nurse-led practice session that looked at Minnesota Nice, Inc a commercial Direct Primary Care model in urban Minneapolis that is co-owned by 2 NPs and a medical economist, and sells medically necessary primary care services to employers on a subscription basis. This DPC does not take commercial insurance. And it does not have a brick and mortar component; instead it relies on telehealth imaging and home visits, including delivery of the meds they prescribe. They provide all the backroom services the mobile practice needs. They are considering franchising the model, including the back room services and the marketing to local employers/consumers. Now compare that mobile nurse-led primary care practice model in MN with S Dakota State University School of Nursing’s MSO [management services organization ] vision [and grant]to support rural South Dakota NP indie practices that may have no brick and mortar base. Like MN Nice, Inc., the MSO will provide a digital platform that becomes the virtual brick and mortar, allows the practices to share data and contract as one Virtual Group for value-based reimbursement contracts with payers. And like MN Nice, Inc, the MSO offers NP practices an outsourced backroom function and an organizational structure that is poised for the best aggregation and leveraging of NP cost-effective and quality outcomes with payers.
We recognized several common features embedded in both these Midwest primary care models–the commercial DPC in MN and the academic MSO in South Dakota — that may foreshadow what a sustainable indie NP-led practice will look like in a few years—and maybe what we should be working toward now:
I haven’t even gotten to the NP Value in Value-based Reimbursement session takeaways. Or the HUGE popularity of our Getting Started Speed Dating 10 minute “Ask Anything” sessions with NPE heavy-hitters! We Owe You More—but it’s mutual. You need a Convener and we need you and your critical mass to make us smart. Please commit to membership and join NNPEN now!
Co-Founder and CEO of NNPEN
I’m home a few weeks or so following the first of NNPEN’s Regional NP Entrepreneurship Conference, in Minneapolis. So many lessons to learn! Who knew that we put conferences together for our members but without supportive sponsors we will never break even? [A projected $9K loss is not a good thing for our start-up’s first year but NEVER did we contemplate cancelling the day.] In our defense, we also know much more about what kind of sponsors and exhibitors most naturally align with you, the NPE “market.” Not just product alignment: e.g., cash medicine products and services. But also alignment of vision as to who NPEs are: a burgeoning workforce of small practices together capable of innovation that will disrupt how and where primary care services are rendered? An emerging group of primary care practice owners with purchasing power—NPE buyers creating the same –and different–commercial opportunities that young physician practices once did? We might want to start with how bank lending officers underwrite independent NP primary care practice startups vs independent primary care physician practice start-ups….
I’m reminded that for now, every project we do tells us something new about ourselves. Nothing is just “work”. Right now, it’s all good and that’s a good time to stop for just a bit to savor rewards like this one, tucked into an attendee’s post-conference follow-up to NNPEN:
“20 years ago a group of us had a dream. 20 years later YOU and your team have given it wings! Thank you! Thank you! Thank you!”
A CALL TO ACTION
For NNPEN, hearing from conference attendees and speakers that the NP Entrepreneurship practice gauntlet is being passed to us is reward but it’s also sobering. Like you, we are an NP-led start-up that thinks we can make a difference. Like you, we completed our post conference evaluation form and had to answer the concluding question:
“What step or steps toward ownership will you be taking in the next 12 months as a result of attending this NP Entrepreneurship Conference? “
We will host an Office Ours call for open discussion of attendees’ feedback on this question. As of September, Office Ours will be a Members Only event, so join NNPEN now to ensure your place at the table. We need you!
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