With its advanced practice registered nurses (APRNs) playing a bigger role in everyday patient care, Waco Cardiology Associates recognized a better approach to team-based care.
For a time, the nurses were helping physicians round on hospitalized patients. But as the practice grew, the physicians found they had an increasingly difficult time seeing both new and established patients in the office, says cardiologist Andrew Day, MD. So the practice shifted gears to have its nonphysician practitioners (NPPs) see only established patients in the clinic during the afternoons.
This improved patient service so much that the practice started holding these exams all day.
“We found that having our NPPs see established patients – in accordance with the plan of care [set up] by the patient’s primary cardiologist – has improved our workflow by allowing the cardiologists to see new patients in a more-timely manner and devote more time to performing cardiovascular procedures,” Dr. Day said.
The improved patient care came with an additional benefit: The practice could bill for these NPP visits more effectively and get the most value from the team-based services.
However, because state laws governing physician delegation and supervision can be tricky to navigate – as are insurers’ billing requirements for NPP services – practices must stay up to date to avoid potential penalties.
“This is potentially problematic for these medical practices,” said Brad Davis, practice management consultant at the Texas Medical Association.
Fortunately, TMA has resources to help, including an upcoming seminar at TexMed 2019, TMA’s annual meeting, in Dallas May 17-18. (See “Delegation of Duties,” page 36.)
Making the team work
NPPs can include both APRNs and physician assistants, and medical practices commonly overlook certain rules when managing these staff, Mr. Davis says. For instance, physicians must properly and regularly register with the Texas Medical Board (TMB) to delegate medical and prescriptive authority to NPPs, as permitted by Texas law. But practices might forget that delegation also requires physicians to meet specific supervision requirements (spelled out in TMB rules, Chapter 193, tma.tips/TMB Delegation) with the NPPs they oversee.
For example, physicians are required to regularly review a small, random sample of patient charts the NPP has handled.
“You should also go over anything that’s a known issue,” he said. “But it’s a best practice [when reviewing a chart] to make sure the care given was of the same level as what the physicians would have provided.”
Even though the supervision requirements might not be difficult to meet, some practices fail to adhere to all of them, Mr. Davis says, which could invite TMB financial penalties and potentially even the loss of license.
Medical practices have a lot to consider when they hire NPPs, Mr. Davis says. Many employ them to help ease heavy workloads on physicians and to expand access to care for patients, such as via longer clinic hours or more appointment slots.
Dr. Day says using NPPs to follow up on previous exams by physicians makes sense for Waco Cardiology because it frees up the doctors to establish treatment plans for other patients with chronic conditions. On the other hand, surgical practices might use NPPs to assist surgeons or do simple procedures on their own, he says.
Practices also should weigh quality-of-life issues when they explore hiring NPPs, Dr. Day says. For some physicians, a lighter caseload is paramount so that they can achieve a better work-life balance. Other practices are more concerned with improving their financial operations. Neither’s wrong, he says – they’re just different ways of running a practice.
“You have to define what your priority is,” he said.
There are financial considerations as well. And understanding how insurers’ billing rules interact with practices’ team-based care protocols can help maximize those team efforts.
For example, allowing qualified nonphysicians to see established patients for follow-up visits like Waco Cardiology did, meant the practice could receive payment for those services at a higher rate than if the NPPs were to see new patients or see established patients with a new condition.
However, practices often misunderstand such billing rules for a simple reason: There’s a big difference between NPPs’ scope of practice and their scope of billing, Mr. Davis warns. For scope of practice, NPPs can do anything their supervising physician is comfortable with delegating under the physician’s license. Many physicians give NPPs latitude, for example, to see new patients or to staff satellite offices where no physician is physically present.
But billing for the nonphysician services is much more constrained, Mr. Davis says. For instance, whether an NPP sees patients in the same office as his or her supervising physician – versus a satellite office – affects how practices get paid for those services.
“That’s one of the biggest issues,” Mr. Davis said. “[Practices] try to staff two locations when you can’t really do that using NPPs without being paid [a] lesser amount.”
NPPs can avoid such billing pitfalls by identifying their on-site supervising physician in their documentation for each patient, Mr. Davis says. Under Texas law, physicians can delegate prescriptive authority to up to seven NPPs.
“[The NPP] should always say, ‘I’m being supervised by Dr. So-and-So [in the same office],’” he said. “As long as you have an [employer-employee] relationship under the same tax ID, you can be a supervising physician of that NPP.”
Waco Cardiology had to create processes to identify and differentiate between new and existing medical conditions to ensure the NPPs were billing properly. One way to do that was by identifying whether a care plan was in place, likely signaling an established patient.
“Generally, the NPPs see patients with chronic problems for which a care plan has already been established by the cardiologist,” Dr. Day said. “However, occasionally patients do present with new problems. When this occurs, the practice does not bill [the same way] for those NPP visits.”
Without their own strategy in place, practices risk not getting adequately paid for the level of care their practice provided, or having to reimburse insurers for overpayment, Mr. Davis cautions. “That’s the biggest thing that we see [medical practices] doing wrong.”
May 2019 Texas Medicine Contents
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