NON-PHYSICIAN PROVIDERS December 1 2010 Renee H Martin

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 Tel. : (610) 423 -4200 Fax: (610) 423 -4201 E-mail: rmartin@tshealthlaw. com

Healthcare Reform n There is currently a 30% shortage of primary care physicians n Patient Protection and Affordable Care Act (“PPACA”) expands the use of nonphysician providers (NPPs) to provide care in a less expensive manner n This then expands the availability of physicians to provider services that require a higher level of medical skill Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 2

PPACA & NPPs n Creates additional educational funding for primary care, geriatric and pediatric PAs and CRNPs n Fully integrates the PAs and CRNPS into the Medical Home Demonstration projects n Creates a 5 year 10% incentive payment for primary care services for PAs, CRNPs, and CNMs n Permits PAs to write orders in SNFs Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 3

PPACA & Nurses n Provides federally qualified health centers or nurse-managed health centers 3 year grants to fund recent family nurse practitioner graduates n 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 Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 4

PPACA & Nurses n Provides funding to improve care transitions for high-risk Medicare beneficiaries to reduce costly re-hospitalizations n Increases Medicare payment rate for covered services provided by certified nursemidwives from 65% of physician fee schedule to 100% Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 5

NPP‘s Legal Perspective Pennsylvania 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 Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 6

Physician Assistant Pennsylvania Law n “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) Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 7

Physician Assistant Pennsylvania Regulations n “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) Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 8

Physician Assistant Supervisor n Primary PA Supervisor – Must be a currently licensed M. D. n Substitute PA Supervisor – Provides supervision in absence of primary supervisor; may be M. D. or D. O. n All supervisors must be registered with & approved by State Board of Medicine Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 9

Responsibilities of Physician Assistant Supervisor n 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 Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 10

Ongoing Responsibilities of 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 Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 11

Ongoing Responsibilities of 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 Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 12

Physician Assistant Written Agreement n Between Physician Assistant and each Supervising Physician (at least 1 must be a M. D. ) & signed by all n Describes manner Physician Assistant will assist each Supervising Physician – List procedures/tasks – Instructions as to how to perform tasks – Medical regimens administered/relayed n List times, manner, place of supervision – Frequency of personal contact with Physician Assistant n Require Supervising Physician to countersign patient record completed by PA within 10 days n List locations and practice settings n Approval by Board of Medicine required Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 13

Physician Assistants. Prohibitions A Physician Assistant may not: n Perform a medical service without the supervision of a n n 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 Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 14

Physician Assistant - Prohibitions (cont’d. ) A Physician Assistant may not: n Independently delegate a task assigned to him by the PA Supervisor to another health care provider n List name independently in a phone directory, etc. that looks like the PA is an independent practitioner Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 15

Physician Assistant Prescribing/Dispensing Drugs n Authorized to prescribe, dispense & administer drugs & therapeutic devices as delegated by Physician Supervisor n May not prescribe/dispense Schedule I controlled substances n May only prescribe/dispense drugs for patients of PA’s Physician Supervisor & as provided by Physician Supervisor’s directions & Written Agreement n May request, receive & sign for professional samples & distribute them to patients Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 16

Physician Assistant Prescribing Authority n May prescribe Schedule II controlled substances for initial therapy: – up to 72 hour dose – must notify Physician Supervisor ASAP (24 hrs max) n May prescribe Schedule II controlled substances for ongoing therapy: – up to a 30 day supply (if approved by Physician Supervisor for ongoing therapy) n Prescription must clearly state whether its initial or ongoing Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 17

Certified Registered Nurse Practitioner (CRNP) n CRNP is an advanced practice registered nurse who holds a graduate degree in nursing (masters or doctoral) n 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 Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 18

CRNP n Unlike a PA, CRNP practices with a high degree of professional autonomy & does not require a delegation from a physician to provide care n NPs can practice on their own in 50% of states n Can specialize in everything from family practice to orthopedics Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 19

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 Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 20

CRNP Supervising Requirements n “Collaborating” Physician n Physician Licensed in Pennsylvania n Either M. D. or D. O. n Substitute Physician n No Board approval requirements Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 21

CRNP Collaborating Requirements n Immediately available: direct communications, radio, telephone or telecommunications n A predetermined plan jointly developed for emergency services n 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 Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 22

CRNP Collaborating/Prescriptive Agreement n Identify CRNP, collaborating & substitute physician n Identify areas of practice/categories of drugs n Physician attestation that CRNP has n n 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 Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 23

CRNP Prescriptive Authority Collaborative Agreement n Between a physician & CRNP who will dispense drugs & other medical therapeutic or corrective measures n 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 Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 24

CRNP Collaborating Agreement n 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 Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 25

CRNP Prescribing Authority n 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 n Enter into Collaborating Agreement with physician Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 26

CRNP Prescribing Authority (cont’d. ) n Effective 12/2009, CRNPs may prescribe Schedule I Narcotics n 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 n Rx includes CRNP’s name, title & certificate; also CRNP’s NPI number when appropriate Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 27

Medicare – Billing Requirements n Covered services are those the PA or CRNP is legally authorized to perform under state law n Covered services are now permitted to include CRNP’s supervision of diagnostic tests under the CRNP’s NPI Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 28

Medicare Billing 3 Ways to Bill n “Incident to” n Independent/Direct (under own NPI)

Medicare Billing and Reimbursement n “Incident To”: Paid 100% of physician’s fee schedule by billing using the physician’s NPI n Independent/Direct: Paid 85% of physician’s fee schedule by billing using the PA’s or CRNP’s NPI Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 30

“Incident To” Requirements n Integral, although incidental, part of the physician’s professional services n Commonly rendered without charge or included in the physician’s bill n Type commonly furnished in physician’s office/clinic (not hospital) n Physician performed the initial service/remains actively involved in treatment n Furnished under physician’s direct personal supervision n Furnished by physician or physician employee Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 31

“Incident To” Direct Personal Supervision: n Office Setting – Present in office suite – Immediately available to assist/direct – Availability by telephone ≠ direct supervision n Group Practice – Any physician member of group can supervise Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 32

“Incident To” n NPP may be employee, leased employee or independent contractor of physician or the legal entity that employs or contracts with the physician. n Sponsoring physician may be employee, leased employee or independent contractor legal entity billing and receiving payment for services. Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 33

Independent/Direct Billing: Physician Assistant n Bill under Physician Assistant’s NPI n “General” supervision required (not physically present) n Payment made to Physician Assistant’s employer n Service covered if rendered by a physician n Service legally performed by PA in state n Directly provided by Physician Assistant n Must accept assignment Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 34

Independent/Direct Billing: CRNP n RN/Certified as a NP by recognized certifying body n Possess a master’s or doctoral level in Nursing n Services are type considered physician’s services n Work in collaboration with a physician (look to state law) n Medicare covered services n Direct billing under the CRNP’s NPI and payment to the CRNP or employer n Assignment is mandatory Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 35

Billing of Shared/Split E&M Service n Hospital inpatient, outpatient/ER setting n E/M Service is a split/shared encounter between physician and NPP in same group practice n Service may be performed at different times of the day n Correlate the 2 visits to a single level of service n Physician must perform some portion of the faceto-face encounter Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 36

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 Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 37

Split E/M Billing vs. “Incident To” 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 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 Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 38

Medical Assistance Physician Assistant n May not enroll directly with DPW, follow “incident to” n Will pay for both outpatient and inpatient services performed by Physician Assistant n Bill under Supervising Physician’s provider # n Payment made at Physician’s rate n Supervising Physician accessible by telephone/other means (no direct supervision required) Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 39

Medical Assistance CRNP n May enroll with DPW n Complete application n Provide copy of Collaboration Agreement n Paid at physician’s rate n If not enrolled, follow “incident to” rules Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 40