This horror story involves a nurse practitioner led practice in North Carolina.  It started out like so many other clinics, an excellent nurse practitioner moves to an underserved area and opens her own clinic.  Unfortunately, nurse practitioners in the state of North Carolina (supervision/scope of practice requirements) are required to have a supervising physician and do not have independent prescribing or diagnostic authority.  This nurse practitioner was aware of the law and proceeded to find a qualified physician to provide supervision in her new practice.

She found a great board certified family medicine physician to provide supervision and she was on her way to having a vibrant practice. Unfortunately, it’s not enough to just find a supervising physician and hope that they take care of the paperwork involved in registering as your supervising physician.  It’s also not enough to trust that the physician supervising your medical services doesn’t already have a dozen other nps that he/she is providing the same services to.

I wish this story had a happy ending but it does not.  She hit the ground running, got her practice credentialed with the insurance companies, Medicare, NC Medicaid, selected her billing company and started marketing her new practice with a beautiful new website.  After only one year, she was seeing an average of 28 patients each day and even introduced some ancillary services within her practice.

Little did she know, her practice was about to fall apart and her life would never be the same.

Here are the four issues that shut down a nurse practitioner’s private practice:

  1. The physician, while well-meaning, was also supervising 11 other nurse practitioners spread out across 3 counties.  It was ruled that he could not sufficiently meet the supervision standards as he was rarely available to the nurse practitioner.  It’s important to consider to recognize the distinction between a supervising physician in title only and one that is actually involved in your practice.
  2. The local billing company (that came with excellent recommendations) failed to submit claims properly.  While each state has their own definition of what supervision entails, the federal government trumps any local laws when it comes to billing.  You’re required to submit claims under the nurse practitioner for any Medicare new patients or established patients presenting with new problems.  One can argue that the billing company was aware of this provision(they certainly should be) and that they simply billed all claims under the supervising physician because of the 15% reduction in payment for NPs when billing under their own Medicare number.  The whole case against the NP might not have ever been brought up if a patient hadn’t complained about fraudulent billing because an EOB showed a physician’s name that she had never met or heard of.
  3. If the supervision of too many NPs wasn’t enough, the physician also had disciplinary action against him which all but eliminated his prescribing authority.  Nurse practitioners in NC do not have independent prescribing authority to it’s important to verify that your physician doesn’t have any current or pending lawsuits which limit his/her prescribing authority.
  4. Finally, the NP was told that she would be covered under her supervising physician’s malpractice policy which was never done.  It is true that you can be a rider on your supervising physician’s malpractice policy but they have to submit the paperwork and pay the fees to make this happen.  Their failure to do so isn’t just their problem, it could come back to bite you in the butt like it did with this NP.  We always recommendhaving your own policy to prevent issues down the road when your supervising physician forgets to renew or decides unilaterally that it’s not worth the extra money to cover you.

At the end of the day, the nurse practitioner was fined hundreds of thousands of dollars under the false claims act, forced to shut down her practice and now has a restricted license in the state of NC.  You may say that this is a really rare occurrence but it’s happening a lot more than you think.  Do your due diligence when starting your practice and take steps to ensure this scenario doesn’t replay in your life.  It’s NOT worth it!!

For assistance with starting your np private practice or help with insurance credentialing and contracting, visit our NP Credentialing Services page here.

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Understanding Practice Status of Nurse Practitioners

Scope of practice guidelines for advanced nursing professions vary by state as indicated above.  As of today, there are 21 states and the District of Columbia which have approved “full practice” (Kaiser Family Foundation) status for Nurse Practitioners.  This provision allows NPs the ability to access, diagnose, interpret diagnostic tests, and prescribe medications independently.

As of 2010, full practice status became the recommended model by the Institute of Medicine and the National Council for State Boards of Nursing. However, not all states are on board with the measure.  In the US today, there are 29 states that continue to mandate reduced or restricted practice regulations for Nurse Practitioners. While the practice guidelines for both of these levels are slightly different depending on location, all require NPs to have either a signed collaboration agreement with a physician or direct oversight from a physician. Not all states require the physician to be physically present, be in the same building or even have limits on how many NPs a physician can supervise but your collaborating physician should always be available by phone or email.

NP Independent Care Gaining Steam

Despite aggressive opposition from the medical community, some legislators are looking expanding coverage to underserved areas and easing the burden on the dwindling number of primary care physicians who remain — calling the NP role “necessary for long-term health care.”

Nurse Practitioners have full practice authority inthe following states.  Here is a helpful link when evaluating different states and the laws in place.  AANP regs by state

  • Alaska
  • Arizona
  • Colorado
  • Connecticut
  • District of Columbia
  • Hawaii
  • Idaho
  • Iowa
  • Maine
  • Maryland
  • Minnesota
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Mexico
  • North Dakota
  • Oregon
  • Rhode Island
  • Vermont
  • Washington
  • Wyoming

According to the Kaiser Family Foundation, “in 2013, more than 20 states took legislative or regulatory action favorable to NPs’ ability to practice more fully.” Several states have also approved new legislation for NPs, empowering them to sign death certificates and formal health records and affording them the ability to prescribe certain medications.

With the approval of HB 4334 last year, West Virginia became the latest state to pass legislation allowing Nurse Practitioners to diagnose and treat patients without the oversight of a physician.  This is great news, however, West Virginia still does not allow NPs to prescribe independently. Most supporters of the bill are hoping that a wider scope of practice will allow more than 1,700 NPs in the state to provide health care to communities where physicians are hard to find.

In addition, states aren’t the only ones moving to unravel practice barriers. In May, the U.S. Department of Veteran Affairs (VA)issued a proposal that would allow full practice authority to all VA advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment.

Communication and Collaboration in the Future

Health care leaders across the board agree that we need more conversations addressing the use of NPs as independent practitioners.  The physician shortage isn’t going away and NPs are the best solution we have to this problem.  Both sides concur that the role of nurse practitioners is vital to the health and delivery of medical care in this nation.  Unfortunately, neither can agree on the best way to achieve this goal.

Here is another helpful link from Kaiser: