NPP Partners

They Can Improve Care and the Bottom Line

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Practice Management Feature – March 2012

Tex Med. 2012;108(3):27-32.

By Crystal Conde
Associate Editor   

Hiring nonphysician practitioners (NPPs) can help medical practices improve patient care and increase reimbursement. Practices have found that NPPs can be valuable members of the health care team.

However, physicians must remember that they are responsible for ensuring that NPPs such as physician assistants (PAs) and nurse practitioners (NPs) stay within their scope of practice and that billing regulations are not violated.

The demand for NPPs is rising.

The American Medical Association reports the number of U.S. physicians increased 29 percent from 1996 (737,764) to 2008 (954,224). The Health Resources and Services Administration says the number of NPs increased 123 percent from 70,993 to 158,348 during that same period. According to the American Academy of Physician Assistants, the number of PAs grew 153 percent from 29,161 in 1996 to 73,893 in 2008.

NPP utilization among physicians reflects their growing numbers. "Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants in Physician Offices," an August data brief published by the Centers for Disease Control and Prevention (CDC), indicates 49 percent of office-based physicians use PAs, NPs, and/or certified nurse midwives (CNMs). The brief highlights the percentage of physicians using NPs, CNMs, or PAs by specialty, age, revenue source, and practice size.

NPPs' increasing demand and use among physicians can be attributed to the economy, improved training, and technology, says Julian Rivera, JD, an attorney in the Austin office of Brown McCarroll, LLP. Mr. Rivera represents physicians in legal matters related to NPP utilization. 

"Patients and payers are demanding lower costs and higher efficiency. Technology is facilitating communication between NPPs and supervising physicians. Electronic health records, electronic prescribing, and electronic communication tools allow physicians who supervise NPPs to examine data in real time, integrating care and ensuring everyone is working from the same record," Mr. Rivera said.

According to the Medical Group Management Association's (MGMA's) 2011 Physician Compensation and Production Survey (based on 2010 data), the median salary for a nurse practitioner was $87,649, and median collections were $174,444. A PA's median salary was $90,001, with median collections totaling $167,336.

The same survey in 2009 found that for every dollar of charges a PA generates for a medical practice, the employer pays an average of 30 cents to employ the PA, not including overhead costs.

Texas Medical Association Practice Consulting offers a variety of services that can help practices hire NPPs and make sure they follow coding and documentation and billing and collections requirements. (See "TMA's NPP Resources.")

"TMA Practice Consulting is an incredibly helpful management resource for physicians who work with or plan to work with NPPs. TMA Practice Consulting understands the many levels of complexity to supervising NPPs," said Mr. Rivera. 

NPP Billing, Credentialing

Proper credentialing is key to the financial success of a practice that employs NPPs.

Practices that use NPPs have two options for getting paid: billing under the NPP's provider number or billing the services "incident to" under a supervising physician's provider number. In other words, when billing "incident to," an NPP's services may be billed as if a physician provided the services. "Incident to" refers to services and supplies commonly furnished in a physician's office that are related to the physician's services.  

Billing "incident to" requires supervising physicians to adhere to stringent requirements. For example, the physician must be in the office suite and immediately available to assist during the NPP's treatment.

Additionally, NPPs can't bill "incident to" for new Medicare patients or Medicare patients who present with a new medical problem. NPPs who bill "incident to" don't have to be individually enrolled in health plans.

"Incident to" is a Medicare billing policy and therefore may not be clearly addressed by other payers. In fact, Mr. Rivera says some commercial insurance plans adopt the Medicare standard for "incident to" billing, and some don't have a policy on "incident to" billing at all. If an insurer lacks an "incident to" policy, Mr. Rivera advises physicians to consult an attorney.

"Legal requirements for physicians who work with NPPs are often changing, and in some cases it's an opaque area of a physician's business. It's wise for a practice to consult with trusted counsel at the business and legal level to ensure patient care is being delivered with high quality, good efficiency, and complete compliance," he said.

Medicaid allows physicians to bill for the services of other practitioners in specific circumstances. For example, Medicaid says that for a PA, "[e]nrollment as an individual provider is optional. PAs currently treating clients and billing under the supervising physician's provider identifier may continue this billing arrangement."

Billing under the NPP's provider number may be simpler than billing "incident to" from a documentation and supervision standpoint, but it could result in lower payments and involves some administrative work in credentialing NPPs with health plans.

When an NPP is able to bill "incident to" using the physician's provider number, the practice receives 100 percent of the allowable charge. But if a physician isn't available and the NPP has to bill under his or her own provider number, the practice receives a reduced percentage of the allowable charge.

Most payers, including Medicare and Medicaid, separately enroll NPPs. Obtaining a billing number for an NPP should involve the same credentialing steps as for a physician. Mr. Rivera says a practice should review payer policies for specific limitations related to NPPs.

"Next, physicians need to analyze how those requirements can be implemented efficiently within the practice. For instance, many payers require a physician to examine a new patient first before NPPs can initiate 'incident to' billing," he said.

Billing "incident to" and billing under the NPP's provider number have additional Medicare and Medicaid limitations, which TMA's Nonphysician Providers: Hiring, Billing and Delegation of Duties for a Nonphysician Practitioner addresses in detail.

NPP Scope, Supervision

Texas licenses PAs and advanced practice nurses (APNs), including nurse midwives and certified registered nurse anesthetists. PAs and APNs differ in their educational requirements, licensure, and regulation but often provide similar services, such as conducting physical examinations, creating therapy plans, and counseling patients. The primary difference between a PA and an APN is that, under certain circumstances, an APN can practice nursing independently of a physician while a PA cannot practice medicine independently.

Mr. Rivera describes NPPs as "extensions of the physician by law," a distinction that has advantages.

"Many NPPs have very specialized training in a particular medical specialty in addition to tailored training they receive from supervising physicians in certain practice settings," he said. 

He stresses that it's important for NPPs to function as part of a physician-led team and within their scope.

Generally, NPPs can provide acute and critical care, take patient histories, perform physical examinations and well visits, order and interpret lab tests, prescribe drugs within state regulations, perform and assist in minor surgeries, provide patient education and counseling, make referrals, and handle other responsibilities.

PAs' and APNs' scope of practice includes providing any medical service delegated by a physician that is consistent with the person's training, education, and experience. Consult Section 204.202 of the Texas Occupations Code relating to scope of practice for PAs for more information. (Note: See the TMA website for direct links to this and the other online resources mentioned in this article.)

APNs also provide a broad range of health services, the scope of which is based on the APN's license, education, experience, and particular specialty area. APNs and PAs practice in various settings, including primary and alternative practice sites, medically underserved regions, and facility-based practices. 

The Texas Board of Nursing and the Nursing Practice Act do not specifically list acts an APN may perform. The only guidance provided is that registered nurses (RNs) must exercise good professional judgment in accepting assignments and/or performing procedures. The Nursing Practice Act says RNs, including APNs, may not engage in activities that require independent medical diagnosis. Without definitive guidance regarding what a registered nurse may do, determining what an APN may and may not do is difficult.

Mr. Rivera suggests physicians consult the Texas Board of Nursing for information about the various specialty certifications for APNs. In addition, he says specialty professional societies for physicians and APNs can provide resources for scope-of-practice protocols, billing and documentation guidance, and supervision and compliance requirements.

Appropriate physician supervision of NPPs must ensure NPPs don't overstep their legal boundaries. Physician supervision requirements for PAs and APNs are different. Delegation of prescriptive authority has supervision rules, which vary by practice site – medically underserved populations, primary sites, alternate sites, and facilities.

For additional guidance, consult TMB's Site-Specific Prescriptive Delegation Statute and Rule Chart [PDF]. The chart includes links to the Texas Occupations Code and Texas Administrative Code for information on site-specific requirements for delegating physicians, chart reviews, site visits, supervision, and more.

For instance, state law requires supervising physicians to randomly review 10 percent of charts for NPPs who practice at alternate sites.

NPPs can't prescribe drugs classified as C2 by the federal Controlled Substances Act. This category includes drugs such as morphine and hydromorphone, which have prescriptions tracked by the Drug Enforcement Agency (DEA). NPPs can write prescriptions for controlled substances categorized as C3, such as Vicodin and codeine.

TMA's Nonphysician Providers: Hiring, Billing and Delegation of Duties for a Nonphysician Practitioner provides more information about physician supervision of NPPs.

NPP Rules, Regulations

Under the state's Medical Practice Act, supervising physicians who delegate certain medical acts must make sure the person does not represent to the public that he or she has authorization to practice medicine. Also, physicians should determine the medical act:  

  • Can be properly and safely performed by the person to whom the medical act is delegated;
  • Is performed in its customary manner; and
  • Is not in violation of any other statute.

The law adds that the delegating physician is "responsible for the medical acts of the person performing the delegated medical acts."

Texas Medical Board (TMB) Executive Director Mari Robinson, JD, says violations of physician oversight of PAs and APNs vary in severity. Physicians who wish to delegate prescriptive authority to PAs and APNs must register on the TMB website. Failure to register prescriptive delegation is an administrative violation that can carry a fine of up to $5,000 per incident.

Improper supervision of and delegation to PAs or APNs could result in the board requiring offending physicians and NPPs to complete continuing education, undergo chart monitoring, and possibly pay fines. Ms. Robinson says patient complaints are the prime source of alleged supervision and delegation violations. 

"If a patient walks into an orthopedic practice and is seen only by a PA who admits never having treated that patient's type of injury, the physician and PA are likely going to run into a delegation violation. If a physician takes a two-month vacation and has no communication with or oversight of an NPP during that time, that physician has a supervision issue," Ms. Robinson said.

Because the legal requirements for working with NPPs are complex and detailed, Ms. Robinson suggests physicians have an attorney review their protocols to ensure they're meeting TMB rules and adhering to state law.

Mr. Rivera says physicians often face challenges pertaining to supervision, scope of practice, contracts, and compliance when using NPPs. He says it's a good idea for physicians to have protocols in place that describe NPPs' scope of practice and articulate their practice parameters.

"For example, in an orthopedic practice setting, it's helpful for a physician to have protocols that outline NPP treatment of chronic versus acute pain. That way, the NPP has appropriate guidance about how care should be provided and explicit instructions from the physician regarding the NPP's scope," Mr. Rivera said.

To avoid disputes, Mr. Rivera says physicians should execute clear employment contracts with the NPPs and create a well-defined compliance plan to confirm an NPP's scope of practice is appropriate and meets quality of care measures. Strong, effective compliance plans incorporate legal requirements, practice policies, risk management efforts, quality control measures, and data gathering, Mr. Rivera says. In addition to having a compliance plan, Mr. Rivera says it's key for a practice to confirm NPPs and physicians adhere to the plan by meeting regularly and documenting fulfillment of requirements.

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.


TMA's NPP Resources

TMA has myriad tools to help physicians manage nonphysician practitioners (NPPs) properly. The TMA Office of the General Counsel wrote a white paper titled "Delegation of Duties by a Physician to a Non-Physician" with information on delegation of medical acts and prescriptive authority, standing delegation orders, physician supervision, and other topics. View it on the TMA webiste or contact the TMA Knowledge Center at  (800) 880-7955 or knowledge[at]texmed[dot]org to request a copy.

In February, TMA began offering the seminar Nonphysician Providers: Fundamentals of Billing and Supervision to inform physicians about recruiting and supervising NPPs, documenting supervision and oversight, and billing appropriately for NPP services. Log on here or call (800) 880-7955 to register. It offers 3 hours of continuing medical education credit.

Nonphysician Providers: Hiring, Billing and Delegation of Duties for a Nonphysician Practitioner is also available for sale from TMA. The publication, by TMA Practice Management Consultant Laura Palmer, FACME, and attorney Julian Rivera, JD, covers prescriptive authority, physician liability, NPP scope of practice, physician supervision, standing orders, documentation requirements, hiring NPPs, billing, credentialing with government and private payers, and more. Call the TMA Knowledge Center, (800) 880-7955, for information about the publication.

TMA Practice Consulting can also help physicians with their NPP needs in recruiting, billing, and coding.

TMA Practice Consulting services are available for a fee. To schedule recruiting services, a billing and collections assessment, a coding and documentation review or training, or other services, call (800) 523-8776, or e-mail TMA Practice Consulting

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