NON-PHYSICIAN PROVIDERS December 1, 2010 Renee H. Martin, Esquire, JD, RN, MSN Tsoules, Sweeney, Martin & Orr, LLC 29 Dowlin Forge Road Exton, PA 19341

NON-PHYSICIAN PROVIDERS

December 1, 2010

Renee H. Martin, Esquire, JD, RN, MSNTsoules, Sweeney, Martin & Orr, LLC

29 Dowlin Forge RoadExton, PA 19341

Tel.: (610) 423-4200Fax: (610) 423-4201

E-mail: [email protected]

Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 2

Healthcare Reform

There is currently a 30% shortage of primary care physicians

Patient Protection and Affordable Care Act (“PPACA”) expands the use of non-physician providers (NPPs) to provide care in a less expensive manner

This then expands the availability of physicians to provider services that require a higher level of medical skill


PPACA & NPPs

Creates additional educational funding for primary care, geriatric and pediatric PAs and CRNPs

Fully integrates the PAs and CRNPS into the Medical Home Demonstration projects

Creates a 5 year 10% incentive payment for primary care services for PAs, CRNPs, and CNMs

Permits PAs to write orders in SNFs


PPACA & Nurses

Provides federally qualified health centers or nurse-managed health centers 3 year grants to fund recent family nurse practitioner graduates

Provides money for the National Health Service Corps, which offers loan forgiveness to primary care providers, including nurse practitioners, who agree to work in rural & remote areas


PPACA & Nurses

Provides funding to improve care transitions for high-risk Medicare beneficiaries to reduce costly re-hospitalizations

Increases Medicare payment rate for covered services provided by certified nurse-midwives from 65% of physician fee schedule to 100%


NPP‘s Legal PerspectivePennsylvania Regulations

Physician Assistants– 49 Pa. Code § 18.121 – § 18.183– Regulated by the State Board of Medicine

Certified Registered Nurse Practitioners– 21 Pa. Code § 21.251 - § 21.321 – Regulated by the State Board of Nursing


Physician AssistantPennsylvania Law

“A physician assistant shall not perform a medical service without the supervision and personal direction of an approved physician.”

63 P.S. 422.13(d)


Physician AssistantPennsylvania Regulations

“The physician assistant practices medicine with physician supervision. A physician assistant may perform those duties and responsibilities, including the ordering, prescribing, dispensing, and administration of drugs and medical devices, as well as the ordering, prescribing, and executing of diagnostic and therapeutic medical regimens, as directed by the supervising physician.” 49 Pa. Code § 18.151(a)


Physician Assistant Supervisor

Primary PA Supervisor– Must be a currently licensed M.D.

Substitute PA Supervisor– Provides supervision in absence of primary

supervisor; may be M.D. or D.O. All supervisors must be registered with &

approved by State Board of Medicine


Responsibilities of Physician Assistant Supervisor

Prior to start date, primary supervisor must:– Complete application– Register with the Board of Medicine– Enter into Written Agreement with Physician

Assistant– May not permit a PA to engage in conduct

prohibited by law – May not have primary responsibility for more than 2

PAs– Must timely review (within 10 days) PA’s medical

records to ensure they are legally compliant


Ongoing Responsibilitiesof PA Supervisor– Monitor compliance with Written Agreement and

state laws

– Advise party to Written Agreement of any failure to conform with its standards or with state laws

– Arrange for substitute PA supervisor

– Review progress of patient’s care with patient as needed based on medical condition/prognosis or upon patient’s request

– See each hospitalized patient at least once


Ongoing Responsibilitiesof PA Supervisor (cont’d.)

– Provide Written Agreement upon request & provide clarification of PA’s orders & prescriptions relayed to other health care providers

– Accept full professional and legal responsibilities


Physician Assistant Written Agreement

Between Physician Assistant and each Supervising Physician (at least 1 must be a M.D.) & signed by all

Describes manner Physician Assistant will assist each Supervising Physician– List procedures/tasks– Instructions as to how to perform tasks– Medical regimens administered/relayed

List times, manner, place of supervision– Frequency of personal contact with Physician Assistant

Require Supervising Physician to countersign patient record completed by PA within 10 days

List locations and practice settings Approval by Board of Medicine required


Physician Assistants- ProhibitionsA Physician Assistant may not: Perform a medical service without the supervision of a

PA supervisor Provide medical services except those in Written

Agreement Prescribe/dispense drugs except as described in

Written Agreement Maintain/manage satellite location unless the

maintenance/management is registered with the Board Independently practice or bill patients


Physician Assistant - Prohibitions (cont’d.)

A Physician Assistant may not:

Independently delegate a task assigned to him by the PA Supervisor to another health care provider

List name independently in a phone directory, etc. that looks like the PA is an independent practitioner


Physician Assistant Prescribing/Dispensing Drugs

Authorized to prescribe, dispense & administer drugs & therapeutic devices as delegated by Physician Supervisor

May not prescribe/dispense Schedule I controlled substances

May only prescribe/dispense drugs for patients of PA’s Physician Supervisor & as provided by Physician Supervisor’s directions & Written Agreement

May request, receive & sign for professional samples & distribute them to patients


Physician Assistant Prescribing Authority

May prescribe Schedule II controlled substances for initial therapy:

– up to 72 hour dose– must notify Physician Supervisor ASAP (24 hrs

max) May prescribe Schedule II controlled substances for

ongoing therapy:

– up to a 30 day supply (if approved by Physician Supervisor for ongoing therapy)

Prescription must clearly state whether its initial or ongoing


Certified Registered Nurse Practitioner (CRNP)

CRNP is an advanced practice registered nurse who holds a graduate degree in nursing (masters or doctoral)

Provides direct primary care or general medical care to patients in a broad range of health services; can diagnose & manage both acute & chronic medical conditions


CRNP

Unlike a PA, CRNP practices with a high degree of professional autonomy & does not require a delegation from a physician to provide care

NPs can practice on their own in 50% of states Can specialize in everything from family

practice to orthopedics


CRNP – Pennsylvania Regulations

“A professional nurse licensed in this Commonwealth who is certified by the Board in a specialty area and who, while functioning in the expanded role as a professional nurse, performs acts of medical diagnosis or prescription of medical therapeutic or corrective measures in collaboration with a physician licensed to practice in this Commonwealth.”

49 Pa. Code § 21.251


CRNP Supervising Requirements

“Collaborating” Physician Physician Licensed in Pennsylvania Either M.D. or D.O. Substitute Physician No Board approval requirements


CRNPCollaborating Requirements Immediately available: direct communications,

radio, telephone or telecommunications A predetermined plan jointly developed for

emergency services Available on a regular basis for:

– Referrals– Review of standards of medical practice– Establishing/updating standing orders, drug/medical

protocols– Periodic updating in diagnosis and therapeutics– Co-sign records, if needed, for accountability– As stated in the Collaborative Agreement


CRNP Collaborating/Prescriptive Agreement

Identify CRNP, collaborating & substitute physician Identify areas of practice/categories of drugs Physician attestation that CRNP has

knowledge/experience with drugs Describe circumstances/when physician will see patient Conditions when CRNP may prescribe Schedule II Amount of professional liability insurance maintained

by CRNP No longer need to file with the Board; must be readily

available & provided to anyone who requests it


CRNP Prescriptive AuthorityCollaborative Agreement

Between a physician & CRNP who will dispense drugs & other medical therapeutic or corrective measures

Prescriptive authority collaborative agreement MUST:– Be in writing– Identify the parties (including the collaborating physician,

CRNP, & at least 1 substitute physician)– Include the CRNP & collaborating physician’s signatures– Include date agreement is signed & its effective date– Identify the specialty in which the CRNP is certified– Identify the category of drugs from which the CRNP may

prescribe or dispense


CRNP Collaborating Agreement

Prescriptive authority collaborative agreement MUST: (continued)

– Specify the circumstances & how often the collaborating physician will personally see the patient

– Be kept at the primary practice location of the CRNP & a copy filed with the Bureau of Professional & Occupational Affairs

– Be made available for inspection to anyone who requests it, & provided free of charge upon request of a pharmacy/pharmacist

– Be reviewed & updated by the parties at least every 2 yrs– Specify the amount of CRNP’s professional liability insurance


CRNP Prescribing Authority

May prescribe/dispense if:– Submitted application for prescriptive authority

approval to the Board with the applicable fee

– Completed approved CRNP program– Completed 45 hours of course work in advanced

pharmacology within 5 years of date of application– Completed 16 hours of continuing education in

pharmacology every 2 years therafter– Comply with state standards

Enter into Collaborating Agreement with physician


CRNP Prescribing Authority (cont’d.)

Effective 12/2009, CRNPs may prescribe Schedule I Narcotics

Restrictions:– Schedule II controlled substance for up to a 30-day

supply as identified in the Collaborative Agreement– Schedule III or IV controlled substance for up to a 90-

day supply as identified in the collaborative agreement– Cannot delegate authority to another provider

Rx includes CRNP’s name, title & certificate; also CRNP’s NPI number when appropriate


Medicare – Billing Requirements

Covered services are those the PA or

CRNP is legally authorized to perform

under state law

Covered services are now permitted to include CRNP’s supervision of diagnostic tests under the CRNP’s NPI


Medicare Billing3 Ways to Bill

“Incident to” Independent/Direct (under own NPI) Shared visit (shared/split E/M services)


Medicare Billing and Reimbursement

“Incident To”: Paid 100% of physician’s fee schedule by billing using the physician’s NPI

Independent/Direct: Paid 85% of physician’s fee schedule by billing using the PA’s or CRNP’s NPI


“Incident To” Requirements Integral, although incidental, part of the physician’s

professional services Commonly rendered without charge or included in

the physician’s bill Type commonly furnished in physician’s

office/clinic (not hospital) Physician performed the initial service/remains

actively involved in treatment Furnished under physician’s direct personal

supervision Furnished by physician or physician employee


“Incident To”Direct Personal Supervision:

Office Setting– Present in office suite– Immediately available to assist/direct– Availability by telephone ≠ direct supervision

Group Practice– Any physician member of group can supervise


“Incident To”

NPP may be employee, leased employee or independent contractor of physician or the legal entity that employs or contracts with the physician.

Sponsoring physician may be employee, leased employee or independent contractor legal entity billing and receiving payment for services.


Independent/Direct Billing:Physician Assistant

Bill under Physician Assistant’s NPI “General” supervision required (not physically

present) Payment made to Physician Assistant’s

employer Service covered if rendered by a physician Service legally performed by PA in state Directly provided by Physician Assistant Must accept assignment


Independent/Direct Billing: CRNP

RN/Certified as a NP by recognized certifying body

Possess a master’s or doctoral level in Nursing Services are type considered physician’s services Work in collaboration with a physician (look to

state law) Medicare covered services Direct billing under the CRNP’s NPI and payment

to the CRNP or employer Assignment is mandatory


Billing of Shared/Split E&M Service Hospital inpatient, outpatient/ER setting E/M Service is a split/shared encounter between

physician and NPP in same group practice Service may be performed at different times of

the day Correlate the 2 visits to a single level of service Physician must perform some portion of the

face-to-face encounter


Split/Shared E/M Billing

Examples:

Activities of both physician and NPP considered part of the visit

NPP sees hospital patient in AM/Physician sees patient in PM– Bill under either Physician or NPP– Bill combined time for two visits– Physician note must reflect face-to-face encounter

with patient


Split E/M Billing vs. “Incident To” Billing

Billing Element Incident To Split/Shared E/M

Time of Service Expected that it will pretty much occur all at once

Can be distinct times of day

Place of Service Only in an office setting Anywhere, except office

Supervision Physician must be physically present on the premises

No requirement

Type of Patient Established patient only Any type of patient

Who Can Share? NPPs including techs Specifically NPPs

Type of Service E/Ms, minor office procedures E/M services only

Documentation Straightforward and obvious Must correlate the 2 services to equate to level of service billed

Counting Time Time cannot be pooled Non-overlapping time can be pooled

Physician Involvement

Must be present on the premises, but face-to-face time with the patient is not required

Can be independent of NPP service, but face-to-face with patient is required


Medical Assistance

Physician Assistant

May not enroll directly with DPW, follow “incident to”

Will pay for both outpatient and inpatient services performed by Physician Assistant

Bill under Supervising Physician’s provider # Payment made at Physician’s rate Supervising Physician accessible by

telephone/other means (no direct supervision required)


Medical Assistance

CRNP May enroll with DPW Complete application Provide copy of Collaboration Agreement Paid at physician’s rate If not enrolled, follow “incident to” rules

Documents

NON-PHYSICIAN PROVIDERS December 1, 2010 Renee H. Martin, Esquire, JD, RN, MSN Tsoules, Sweeney, Martin & Orr, LLC 29 Dowlin Forge Road Exton, PA 19341