New graduate nurse practitioners inevitably face challenges when it comes to the job market in many locations. Without experience in the provider role, employers can be understandably hesitant to hire. Lack of experience, however, is not the only thing hindering new grad NPs in the job market. Other factors like state scope of practice regulations and payer policies play a role. One such scenario is currently playing out in North Carolina. 

I spoke with the CEO of a healthcare facility in North Carolina a few weeks ago about the clinic’s strategies for bringing nurse practitioners onto their team. Ever an advocate for new grads, I inquired specifically about the facility’s interest and experience hiring new grads. The CEO informed me that the clinic had hired new graduates in the past, but recent changes to the state’s Medicaid reimbursement policies now made this challenging. What happened?

In a nutshell, effective August 1, 2016, NC Medicaid no longer allows services provided by PAs, NPs, CRNAs or CNMs to be billed as “incident-to”. Why is this a big deal?

So-called “incident-to” billing allows nurse practitioners and physician assistants to bill for services rendered as part of a physician’s professional services provided that they meet certain requirements. This type of billing allows services rendered by NPs and PAs to be reimbursed at 100% of the physician fee schedule. Essentially, the bill goes out under the physician’s NPI number even though the nurse practitioner or physician assistant did most of the work. 

North Carolina’s Medicaid program has put a stop to incident-to billing for its patients. Now, NPs and PAs must enroll as Medicaid providers billing exclusively under their own credentials. While this move may appear on the surface to have primarily financial implications, new grads in the state are experiencing unintended consequences of the policy. 

Enrollment as a provider in North Carolina’s Medicaid program can take 3 to 6 months to process according to the clinic administrator I spoke with. If new graduates are only allowed to bill under their own credentials rather than under another provider’s as “incident-to”, then essentially new grads cannot bill for encounters with Medicaid patients during their first 3 to 6 months on the job. For clinics working with Medicaid patients, this is a logistical nightmare. 

Not only are clinics understandably unwilling to forgo the revenue associated with these visits while waiting for provider Medicaid applications to process, scheduling new grad NPs exclusively for non-Medicaid patients isn’t practical in many settings – particularly in practices that work with underserved populations. As a result, many facilities are holding off on hiring new grads at all in order to avoid the headache of floating a provider with limited revenue generating capabilities for the initial months of employment, or waiting several months for them to start working at all. 

So, if you’re a new grad nurse practitioner in North Carolina having difficulty landing your first job, Medicaid reimbursement policies just may be (partially) to blame. 


You Might Also Like: Confessions of a Former New Grad Nurse Practitioner 


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2 thoughts on “Blame North Carolina’s Medicaid Policies for the Tough New Grad Job Market”

  • Is this an unintended consequence?
    Or is this a sly effort to limit the number of primary care providers in NC?
    Or is it simply harassment of mid-levels?

  • North Carolina’s Medicaid program has put a stop to incident-to billing for its patients. Now, NPs and PAs must enroll as Medicaid providers billing exclusively under their own credentials.”

    I can see this type of policy becoming the norm in many states,with the new federal budget cuts to the Medicaid program.

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