On-line articles by Carolyn Buppert
20 Questions to Ask a Prospective Employer
Ask these questions:
Why are you interested in hiring an NP?
Is there any aspect of your practice that you want relief from?
What aspect of your practice would you like an NP to develop?
What is your special interest?
Do you want to pay a salary an hourly rate or percentage of billings?
Will you pay for benefits or would you rather pay a higher rate but without benefits?
If paying for benefits, what would you cover?
Do you want me to purchase my own malpractice policy or do you want to cover me under your policy?
If you cover me under your malpractice policy, is your policy a claims made or occurrence policy?
If your policy is claims made, how much is the premium for a “tail”?
Would you pay the premium for the tail?
If I purchase my own malpractice policy, would you pay me a higher salary or hourly rate?
If, rather than a salary, you would like to pay me a percentage of billings or collections, what is your practice’s collections rate?
If you want to pay me a salary, how many patient visits or RVUs per day do you expect me to handle?
Would you expect me to take call? If so, how often?
How would you compensate me for taking call?
Would you expect me to sign a restrictive covenant or non-compete clause? If so, how would you propose to compensate me for agreeing to limit my future opportunities?
Do you have an overflow of patients?
Do you want me to develop my own panel of patients or do you want all patients to think of you as their primary clinician and me as your assistant?
If you want me to develop my own panel of patients, would you:
Put my name, along with yours
on the office sign
in provider directories
on any advertisements for the practice
Back me up if I have trouble enrolling with insurer/payers
Bill for my services under my name
Provide me with monthly statements of billings, collections, accounts receivable
Let me participate in negotiating fee schedules and resolving problems with claims?
Most of these questions should not provoke anxiety in either the nurse practitioner or the employer. However, questions 11, 13, 16, 17 and 20 may provoke a prickly response. You may want to re-word the questions to suit your own style.
For most questions, there are no right or wrong answers. The objective is to address controversial issues up front rather than be surprised after taking a job. Here are some answers NPs may hear, with comment:
1. Why are you interested in hiring an NP?
“I need someone with interests or skills I don’t have.”
“Profit.” If an employer wants profit, ask how much profit the employer is looking to make from the NP, per year.
2. Is there any aspect of your practice that you want relief from?
“Thursday afternoon clinic”
Almost any answer is acceptable, except “In one month, I’m leaving the country for a month.”
3. What aspect of your practice would you like an NP to develop?
“Nursing home visits”
“Well women care”
Any answer acceptable to the NP is fine.
4. What is your special interest?
Any answer that suits the NP is fine.
5. Do you want to pay a salary, an hourly rate or percentage of billings?
New NPs will want a salary or hourly rate. Experienced NPs may want a percentage of billings.
6. Will you pay for benefits or would you rather pay a higher salary but not provide benefits?
Either answer is fine, depending on the NP’s needs.
7. If paying for benefits, what would you cover?
Health insurance, paid holidays and vacation, paid time and tuition for continuing education are customary.
8. Do you want me to purchase my own malpractice policy or do you want to cover me under your policy?
If the employer wants to cover the NP under his/her own policy, be sure to get the following answers to questions 9 to 11 — “occurrence,” “not expensive” (get an amount), “yes.”
9. If you cover me under your policy, is your policy a claims made or occurrence policy?
Most physician practices have claims made policies. However, occurrence policies are preferable.
10. If your policy is claims made, how much is the premium for a “tail”?
The usual answer is “Don’t know.” However, the NP needs to know, as these premiums are expensive.
11. Would you pay the premium for the tail?
If the answer is “no,” the NP should purchase his/her own occurrence policy. If the answer is “yes,” the NP needs to get the promise in writing, before taking the job.
12. If I purchase my own malpractice policy, would you pay me a higher salary or hourly rate?
If the answer is “no,” it would not necessarily be a deal breaker.
13. If, rather than a salary, you would like to pay me a percentage of billings or collections, what is your practice’s collections rate?
If the answer is 50%, ask for a percentage of billings rather than a percentage of collections. Or, ask for a salary or hourly rate. If the answer is 90%, it is safe to ask for a percentage of collections.
14. If you want to pay me a salary, how many patient visits or RVUs per day do you expect me to handle?
If the answer is more than 25 patients a day or more than 20 RVUs per day, consider asking for a percentage of billings rather than a salary. See Buppert, C., “Productivity Incentive Plans for Nurse Practitioners” for more on this issue.
15. Would you expect me to take call? If so, how often?
Answers vary tremendously. If frequent on-call services — more than 48 hours per month — are required, it is reasonable for an NP to expect compensation for taking call.
16. How would you compensate me for taking call?
NPs are getting $25 per 24 hours to $1000 per week, depending on call activity
17. Would you expect me to sign a restrictive covenant or non-compete clause?
The preferred answer is “no.” If the answer is “yes,” consider this issue a potential deal breaker.
18. Do you have an overflow of patients?
The preferred answer is “yes.” If the answer is “no,” the job may not be long lived.
19. Do you want me to develop my own panel of patients or do you want all patients to think of you as their primary clinician, and me as your assistant?
Either answer is fine, as long as NP and employer agree.
20. If you want me to develop my own panel of patients, may I market myself?
The preferred answer is “yes.”
Copyright 2015, Carolyn Buppert
For further recommendations about negotiating terms of employment, see Buppert, C. Negotiating Terms of Employment.
Billing “Incident To” When an Established Patient Has a New Problem
If the practice situation meets certain requirements, however, a nurse practitioner’s services may be billed under a physician’s provider number, and Medicare will pay 80% of the Fee Schedule rate. Medicare calls that situation “incident to” billing. Here are the circumstances under which a nurse practitioner’s services may be billed incident to a physician’s services, as specified in the Medicare Benefit Policy Manual, Chapter 15, Sections 60.1 to 60.3:
“In addition to coverage being available for the services of such auxiliary personnel as nurses, technicians, and therapists when furnished incident to the professional services of a physician, a physician may also have the services of certain nonphysician practitioners covered as services incident to a physician’s professional services. These nonphysician practitioners, who are being licensed by the States under various programs to assist or act in the place of the physician, include, for example, certified nurse midwives, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialists.
Services performed by these nonphysician practitioners incident to a physician’s professional services include not only services ordinarily rendered by a physician’s office staff person (e.g., medical services such as taking blood pressures and temperatures, giving injections, and changing dressings) but also services ordinarily performed by the physician himself or herself such as minor surgery, setting casts or simple fractures, reading x-rays, and other activities that involve evaluation or treatment of a patient’s condition.
Nonetheless, in order for services of a nonphysician practitioner to be covered as incident to the services of a physician, the services must meet all of the requirements for coverage specified in Sections through 60.1. For example, the services must be an integral, although incidental, part of the physician’s personal professional services, and they must be performed under the physician’s direct supervision. A nonphysician practitioner such as a physician assistant or a nurse practitioner may be licensed under State law to perform a specific medical procedure and may be able (see Section 190 or 200, respectively) to perform the procedure without physician supervision and have the service separately covered and paid for by Medicare as a physician assistant’s or nurse practitioner’s service. However, in order to have that same service covered as incident to the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physician’s personal in-office service. As explained in Section 60.1, this does not mean that each occasion of an incidental service performed by a nonphysician practitioner must always be the occasion of a service actually rendered by the physician. It does mean that there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects his or her continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary. [Bolding provided by author.]
Note also that a physician might render a physician’s service that can be covered even though another service furnished by a nonphysician practitioner as incident to the physician’s service might not be covered. For example, an office visit during which the physician diagnoses a medical problem and established a course of treatment could be covered even if, during the same visit, a nonphysician practitioner performs a noncovered service such as an acupuncture.”
This article addresses only the phrase in bold above.
Consider these three scenarios. (Names have been changed.)
Visit 1: Patient Zeller, a new patient covered by traditional Medicare, is evaluated by MD Oaks in July 2006 and diagnosed with high blood pressure. Dr. Oaks bills a level 3 office visit to Part B under his provider number. The full Physician Fee Schedule rate is applicable, which, in his case, is $94.26.
Visit 2: In October 2006, Patient Zeller is evaluated in follow-up of high blood pressure by NP Stone, an employee of Dr. Oaks. NP Stone codes a level 3 office visit, and Dr. Oaks bills the visit under his provider number. (Dr. Oaks was on-site when the NP conducted the visit.) The full physician rate is applicable, which is $51.68 in this case.
Visit 3: In January 2007, Patient Zeller arrives to see NP Stone for follow-up of high blood pressure. Patient Zeller states “I have another problem. My left ear hurts.” NP Stone evaluates and manages both problems.
The dilemma: Whose provider number should Visit 3 be billed under — Dr. Oak’s or NP Stone’s? Would the appropriate CPT code (assuming all other requirements are met) be a level 4, billed under Dr. Oaks ($81.06), a level 4 billed under NP Stone ($68.90), or a level 3 billed under Dr. Oaks ($51.68)? (Rates differ depending upon geographic area and specialty). Medicare regulations provide no answer to this question.
One of the Medicare Carriers’ web sites said:
“Q: If a nurse practitioner sees an established patient for an established problem, and during the course of the visit diagnoses a new problem, how would the service be billed to Medicare?
A: It is my opinion that the service can be billed ‘incident to.’ The service initially, as scheduled, met the ‘incident to’ guidelines since the patient was seen for an established problem. The only caveat is that the services related to the new diagnoses should not be utilized when determining the level of care for an evaluation and management service. The rationale is that the physician must perform an initial service and subsequent services (for the new condition) of a frequency that reflected his/her active participation in and management of the course of treatment. Therefore, the initial service for the new condition cannot be considered when determining the level of care.”
The web site of a physician organization said:
“Q: …[W]hen the NP is talking to the patient during the exam the patient explains a new problem that has not been addressed before. Can the NP continue to perform the service and have it billed under ‘incident to’ guidelines?
A: In order for the service to be reported under the physician’s provider number, the employing physician should be brought in to see the patient for the new problem and establish a plan of care. This should not pose a problem for the physician as under the ‘incident to’ guidelines, the physician has to be on site in the office suite. Another option is for the NP to see the patient and report the service under the NP’s Medicare provider number.”
Unless and until Medicare administrators provide further guidance, either of these approaches would be appropriate.
Copyright 2015, Carolyn Buppert
Documenting and Rewarding Productivity
“In addition to base salary, the Company may, but shall not be required to, pay the Nurse Practitioner a performance bonus, the amount of which shall be determined by the Company in its sole and absolute discretion, based on a maximum of fifty percent (50%) of net revenues after expenses generated by Nurse Practitioner in excess of one hundred twenty thousand dollars ($120,000.00) per year, not including fees for capitated patients.”
There are 4 things wrong with the wording of this clause. First the words “may, but shall not be required to pay” make it unlikely that the NP ever will get paid a bonus. “May” should be changed to “shall” or “agrees to pay.” Second, it would be in the NP’s interest to have a minimum percentage stated. Stating a maximum percentage does nothing for the NP. Third, the NP should get a percentage of fees for capitated patients she sees. Fourth, the contract should state how often the bonus will be figured and paid.
If we clean up the language, this bonus would be formula is simple. The practice totals the collections on the NP’s fee-for-service billings, subtracts $120,000 from that number, and pays the NP whatever percentage the NP and the employer have agreed upon. Accounting for capitated patients is complicated, however.
Other ways of judging productivity
Provider productivity may be based on the following:
Total gross charges
Total net medical revenue
Revenue minus expenses
Patient panel size
Growth rate of patient base
Visits or consults
Volume of procedures
Number of cases
Productivity may be affected by the time a provider spends at the office, the efficiency of the provider, the fee associated with the procedures the provider performs (some procedures bring in more money than others, some insurers pay higher fees than others for the same procedure), the patients’ ability to hear, understand, communicate and move, the provider’s motivation, and the presence or absence of distractions.
RVUs as a way to determine productivity and compensation
Recently, some practices have been tracking relative value units (RVUs) as a way of measuring and documenting physician and NP productivity. An RVU assigns a value to one CPT code relative to other CPT codes. This is part of a system called the resource-based relative value scale (RBRVS). The RBRVS, developed by the Health Care Financing Administration (HCFA), now the Center for Medicaid and Medicare Services (CMS), is used to determine reimbursement for Medicare Part B services. Under the RBRVS system, services are reimbursed on the basis of the resources expended to perform the procedure rather than simply on the basis of historical trends.
Practices often turn to this method when they employ both primary care providers and specialists. Specialists traditionally are paid more and because their fee schedule rates are higher, may generate more revenue. However, they may not be working harder than the primary care providers. By tracking RVUs, the practice can document the work a clinician performs, irrespective of variation in fees among specialties and health plans. If using RVUs to document work done, salaries can be adjusted based on an accepted measurement, rather than tradition. Furthermore, when a practice is reimbursed under both capitation and fee-for-service, the RVU system captures the work involved in treating capitated patients. Note that the system assumes that providers are adept at selecting the CPT codes that appropriately represent their work. If a provider is not a good coder, and assigns every visit a level 2 (out of 5), then that provider will not get credit for all of his work.
There are three components to a relative value: 1) practice expense component, 2) work component, and 3) malpractice component. The work RVU takes into account the time it takes to perform a service, the technical skill and physical effort involved, the mental effort and judgment required, and the stress due to potential risk. Each component is adjusted geographically using three separate Geographic Practice Cost Indexes (GPCI). The final formula to arrive at an area specific relative value is:
(Practice Expense RV x Practice Expense GPCI)
(Work RV x Work GPCI)
(Malpractice RV x Malpractice GPCI)
= Relative value
The relative value is then multiplied by a single nationally uniform “conversion factor” to arrive at a monetary value.
For example, for CPT 99214, in 2005 the work RVU was 1.10, the practice expense RVU was 1.03 and the malpractice RVU was 0.05. The total RVU for 99214 was therefore 2.18. To convert the RVU to a monetary amount, multiply by the conversion factor (37.8975 in 2005). The payment for CPT 99214 in 2005 was $82.61.
All of the RVUs can be downloaded from the CMS web site. RVUs are updated annually and reviewed in depth every 5 years.
Copyright 2015, Carolyn Buppert
How to Avoid Errors When Writing Prescriptions
An Institute of Medicine report estimated that between 44,000 and 98,000 persons in hospitals in the United States die annually as a result of medication errors. The incidence of errors in office practice is difficult to tabulate, but the following 1999 case is indicative of the potential for disaster:
A cardiologist wrote a prescription for Isordil 20 mg. Because of the cardiologist’s small, cursive handwriting, the pharmacist misread the prescription as Plendil, and dispensed 20 mg pills, which is double the maximum daily dose of Plendil. The patient had a heart attack and died. The patient’s family sued both the cardiologist and pharmacist, and a jury found both liable, and ordered them to contribute equally to the award of $450,000 to the family.
Among the most common errors made when prescribing are:
- indication errors (under use of appropriate medication, overuse of a medication and misuse)
- dosing errors
- drug-drug interactions
- inadequate records (non-documentation of adverse drug events or allergies, for example) and
- misread or misinterpreted prescriptions.
This issue focuses on the last-named error. NPs will want to write a prescription in such a way that there is little chance that the individual dispensing the medication will misinterpret or misread the drug, dose, frequency and route of administration.
Many NPs were taught to write prescriptions using the following symbols and abbreviations:
Rx: Digoxin .25 mg
Sig: Take 1 p.o. qd
Disp: 30 1 refill
Some may have assumed that to write a prescription in any other way might be unprofessional. However, trial, error, research and reflection has taught clinicians that abbreviations are often misread or misinterpreted. For example, qd or QD, has been mistaken as qid, especially when a period is placed after the q or the tail of the q is misread as an “i.” It is safer to write “daily” or “every day.”
Twelve tips regarding use of symbols and abbreviations
- Write “greater than” and “less than” rather than use > or <, which may be misread as the opposite symbol.
- Use “per” rather than a slash mark. The slash may be read as the number “1.”
- Use a clear space between drug name, dose and unit of measure. Inderal40mg could be read as Inderal 140 mg.
- Always use a zero before a decimal when the dose is less than a whole unit. If no zero is written, the decimal may be missed, causing a pharmacist or nurse to dispense 5 mg instead of 0.5 mg.
- Do not use zeros after a decimal point. The decimal point may not be seen, and the dose may be dispensed as 10 mg rather than 1.0 mg.
- Write out “nightly” rather than qhs, which can be misread as “every hour.”
- Write out “subcutaneous” rather than SC, which can be misread as “SL.”
- Write out “for 3 days,” rather than x3d, which has been mistaken for “3 doses.”
- Spell out “sliding scale,” rather than ss, which has been mistaken for 55.
- Write out “unit” rather than U or u, which has been misread as a zero or 4. One hospital nurse saw 4U as 40, and another saw 4u as 44.
- Write out “3 times a week,” rather than TIW or tiw, which has been mistaken as 3 times a day.
- Write out mcg or microgram rather than µ, which can be mistaken for “mg” when handwritten.
How to handle medications will names similar to other medications
The Institute for Safe Medication practices estimates that 25% of the 1200-1500 reports they receive every year of medication-related injuries or deaths are due to confusing drug names.
Here is a list of medications with names which look or sound similar to other medications and which have been named in reports of medication errors:
|Advicor||Altocor||Both are antihyperlipidemics. Prescriber wrote Advicor but meant Altocor.|
|DiaJect||Diastat||Both are anticonvulsants. Route of administration differs.|
|Levaquin||Levsin||A verbal order for Levaquin was documented as Levsin.|
|Sertraline||Soriatane||Prescriber intended Soriatane. Pharmacist misread poor handwriting as Sertraline. Unit secretary and nurse also transcribed order as sertraline.|
|Vicodin||Visicol||Two cases where clinician wrote for Visicol, pharmicist dispensed Vicodin.|
|Tamoxifen||Tamsulosin||Pharmacist stored these two products next to each other, mistakenly dispensed Tamoxifen.|
|Topamax||Toprol-XL||Prescription for Topomax (anticonvulsant) was filled with Toprol (antiadrenergic). Patient took the Toprol; his hallucinations returned.|
|Zebeta, Zetia, Zestril, Zyrtec||An order for Zetia was dispensed with Zebeta. An order for Zetia was filled with Zyrtec. An order for Zetia was filled with Zestril.|
Additional like-sounding or like-appearing drug names:
|Folic acid||Folinic acid|
How to avoid mix-ups
- Provide both generic and brand names on the prescription or order.
- Write the purpose of the medication on the prescription or order.
- Develop a personal policy, office policy or facility policy for giving and taking verbal orders. For example, make it standard policy to repeat the name of the drug, spell the name of the drug, and repeat the dosage ordered.
- Consider selecting medications without nomenclature problems for your personal, office or facility formulary.
- Provide patients with written information about their drugs, so that they will notice errors.
Copyright 2015, Carolyn Buppert
How to Avoid Reimbursement Denials
To get paid, a practice needs to submit a clean claim
Some practices are reporting that their percentage of claims uncollected 60 days after submission is rising. Slow payment may be a business strategy of an insurer or health plan. In some states, legislatures are attempting to remedy that problem by enacting “prompt pay” laws. Sometimes, payments may be slow in coming, or denied, because the practice or facility did not complete all of the necessary steps to submit a clean claim. A clean claim is a billing form which has all of the necessary blanks filled in, and answers which conform to the insurer’s requirements. Here is a checklist for determining whether a practice has completed all of the steps necessary for getting paid:
For Medicare, have you:
- Applied for and received a provider number for the site from which you are submitting the bill? (If billing “incident to” a physician, has the physician received a provider number for the site where services were rendered?) Note that as of May 23, 2007, all providers must have a National Provider Identifier (NPI).
- Submitted an appropriate CPT and ICD code?
- Ascertained that the ICD code you provided has 5 digits? (Or that the appropriate ICD codes is one for which 4- or 3-digit codes are appropriate)
- Made sure that you have chosen an ICD code that indicates that the service is medically necessary? (Example: EKG is not a medically necessary service if the ICD code submitted is for “dysuria”)
- Determined that the service is covered by Medicare? (Example: Yearly physicals are not covered; however a once-in-a-lifetime physical — when the patient is first enrolled in Medicare — is covered.)
- Made sure that your lab is CLIA registered or that you have a waiver. If you have a waiver, the billed test must be one that is on the list of waived tests.
- Ascertained that the patient is covered by Medicare?
- Ascertained that your state law authorizes an NP to perform the service you are billing?
- If a procedure and an evaluation are provided that day, added a modifier -25 to the CPT code for the evaluation?
- Ascertained that the service has not been billed already?
- Provided all of the ICD codes applicable to the patient, including chronic illnesses which may have factored into the decision to order diagnostic tests or referrals that day?
- Billed Medicare electronically, using a HIPAA-compliant system, or, if on paper, used the appropriate form; i.e. the CMS 1500?
For Medicaid, have you:
- Applied for and received a provider number? (Note that some states’ Medicaid will reimburse only family and pediatric nurse practitioners. Some states will reimburse all nurse practitioners.) As of May 23, 2007, all providers must have a National Provider Identifier (NPI).
- Submitted an appropriate CPT and ICD code?
- Determined that the patient’s coverage is current as of the date of service?
- Determined that the service is covered by Medicaid?
- If billing for a lab test, made sure that your lab conforms to any state Medicaid requirements for billing that test?
- Determined whether the patient is covered by a Medicaid managed care plan? If the patient is covered by a managed care plan, an NP may need to be admitted to the health plan’s provider panel.
For commercial indemnity insurers, such as Blue Cross have you:
- Been approved as a preferred provider, if the insurer requires such designation?
- Gotten a provider number with the insurer, if the insurer requires it? Or, as of May 23, 2007, have a National Provider Identifier (NPI).
- Been credentialed with the insurer, if so required? (Note that credentialing can take 120 days to complete.)
- Submitted a CMS 1500 to the insurer, with a CPT and ICD code which appropriately describes the services provided?
- Provided services which are medically necessary (or preventive services covered under the policy) and not excluded by the terms of the policy?
- Used a laboratory approved by the insurer?
- Ascertained that the patient’s coverage is current?
For patients enrolled in a managed care plan (HMO or MCO) have you:
- Applied for and received approval as a network provider?
- Received approval from the patient’s Primary Care Provider to provide the services (unless you are the patient’s PCP)?
- Determined that the service is covered under the patient’s plan?
- Adhered to the terms of the contract between you or the practice and the managed care plan?
- If the patient is capitated, determined that the service you are billing is not included in the capitated fee?
- Submitted the bill on the form the company wants used for such billings? (Usually, the CMS 1500 form.)
- If the service is a diagnostic test provided in-office, have you determined that your contract allows you to bill for the service?
- Determined that the patient’s coverage is current?
What to do in the off hours to make things run more smoothly
- Gather and read all contracts between the practice and insurers or managed care plans. Look for:
- Any requirements regarding billing of nurse practitioner services
- Any requirements for credentialing of clinicians (For example, if a contract says “All physicians providing services to XYZ Managed Care Plan’s patients must be credentialed through XYZ’s process” and nothing is stated regarding nurse practitioners, the practice manager must ask XYZ whether nurse practitioners must be credentialed, or whether a nurse practitioner’s services may be billed under a collaborating physician’s name, if the physician is credentialed.)
- Services excluded from coverage
- Requirements regarding prior approval; for example, from a Primary Care Provider or utilization manager
- Make a chart or grid of insurer’s requirements or limitations. For example:
Billing of NP services Bill NP services under physician’s name Bill NP service under NP’s number Insurer’s name XYZ X ABC X and so on… Coverage of procedures Thin prep Pap Smear only Insurer’s name XYZ X ABC X and so on…
- Periodically analyze the various insurers and managed care plans regarding a) how promptly they pay claims, b) the adequacy or inadequacy of fee schedules and c) how frequently they deny claims. Attempt to negotiate better terms with companies whose fees are inadequate or who do not make prompt payments. Make a business decision whether the practice will do better accepting or declining to accept a company’s patients. Decline to deal with insurers or managed care plans that will not negotiate, will not improve and do not pay promptly.
Copyright 2015, Carolyn Buppert
How to Fire a Patient
A nurse practitioner (NP) has two patients she would like to discharge from her practice.
Patient A came in for a refill for two controlled substances, a sedative and a sleeping pill. The NP refilled the prescriptions, but advised the patient to begin to wean herself from the sedative and switch to an antidepressant. The patient agreed. The NP ordered the antidepressant. The next day, the pharmacist called the NP to report that the patient also filled prescriptions from another clinician for the two controlled substances.
Patient B has no insurance, has run up a bill for $500 over the past six months, and has paid nothing, despite numerous notices.
The NP may terminate the clinician-patient relationship with both of these patients. However, there are five bases the NP needs to cover:
1. If the patient has been assigned to the NP or practice by a health plan or managed care organization, the plan or organization may require the clinician to go through a specific process in order to transfer the care of the patient. The NP should read the contract between the patient’s health plan and the practice, to determine whether the NP may discharge a covered patient from the practice, and if so, what notice or other paper work needs to be filed.
2. Write the patient a letter, stating:
- The NP is terminating the patient-provider relationship as of a stated date 30 days from the date of the letter.
- The NP will provide services for an acute or chronic illness until the date stated.
- The reasons for discharging the patient. See #4, below.
- The patient’s record will be sent to another clinician, on request.
File a copy of the letter in the patient’s chart. Send the letter certified, return receipt requested. If the patient refuses the letter, file the unopened envelope in the patient’s chart and send another letter via regular mail. Note in the patient’s chart that a second letter was sent, the method of delivery and the name of the sender.
3. Search the state Board of Nursing web site to ascertain that the NP is not “abandoning” the patient under any definition or rules of the Board. (If the NP covers the bases listed in this newsletter, that should not be a problem.)
4. Do not discharge a patient because the patient has an unappealing disease, gender, age, race, disability or handicap, unless the NP’s education and training clearly disqualify the NP from caring for such a patient. To terminate a patient for any of these reasons could be a basis for a civil rights lawsuit on the basis of discrimination.
5. Do not terminate a relationship with a patient who is in an acute episode of illness. For example, if a patient is hospitalized, it is not the time to fire the patient. And, hospital emergency departments are restricted by Federal law from refusing to treat patients.
What legal recourse does a patient have, if an NP fires the patient?
A fired patient has a choice of three possible legal actions — file a lawsuit on the basis of negligence (malpractice) or discrimination or report the NP to the Board of Nursing for patient abandonment. If an NP covers the bases stated in this newsletter, the patient will have no basis for any of these actions.
The elements which a patient must prove, in order to mount a successful case against a clinician on the basis of negligence, are:
- Duty of care (a patient-clinician relationship was established)
- Breach by the clinician of the standard of care
- Injury to patient
- Causal relationship between the injury and the breach of the standard of care.
A clinician who starts seeing a patient has a duty to attend to the patient’s needs until the patient terminates the relationship, the clinician terminates the relationship, the clinician transfers the care to another clinician (because, for example, the patient needs a specialist), or the patient is healthy (no further care is medically necessary), unless the clinician initially agreed to care only for a specific episode or aspect of the patient’s illness, such as an emergency department NP who sees the patient for a specific emergency.
If a clinician stops seeing a patient without giving the appropriate notice, the patient can sue the clinician for negligence, if the patient suffers a preventable injury due to lack of medical attention. For example, reconsider the NP who no longer wants to treat Patient A (the patient who got multiple prescriptions for controlled substances from multiple providers). If, rather than officially terminating the patient-clinician relationship, the NP just refuses to take the patient’s calls and instructs the receptionist to say the NP is “out” if the patient comes to the office, and if the patient has an adverse reaction to one of her medications and it continues for so long that the patient suffers an injury attributable to the reaction, the patient could sue the NP for negligence, saying a) the NP owed the patient a duty of care, b) the NP breached the standard of care (did not return telephone calls), c) the patient suffered an injury and d) the injury was related to the NP’s inattention to the patient’s telephone calls.
By firing a patient, the NP is terminating his or her duty to the patient. Terminating an NP’s duty to a patient can be a risk-avoidance measure in itself. For example, if the NP who wanted to fire Patient A changed her mind and continued to see the patient and continued to prescribe narcotics, Patient A may later sue the NP, claiming that the NP negligently prescribed the controlled substances and contributed to the patient’s addiction. The NP would need to mount a defense and prove that the NP followed the standard of care. However, if the NP appropriately fired Patient A, the NP could prove that she had no long-term duty to the patient (by producing the letter of termination). By terminating the patient, the NP avoids the risk of a lawsuit for negligent prescribing.
An example of a Board of Nursing statement on patient abandonment is: “For patient abandonment to occur:
- the nurse must have first accepted a patient assignment, thus establishing a nurse-patient relationship
- the nurse must have severed the nurse-patient relationship without giving reasonable notice to the appropriate person so that arrangements were made for continuing of nursing care
- the patient must be in need of immediate professional care or circumstances must exist which would seriously impair the delivery of professional care to patients.” (New York)
Frequently asked questions
- Do I have to find another provider who will take care of the patient? No, if the bases listed above have been covered.
- If the appointment scheduler does not realize I have terminated the patient and schedules an appointment, do I need to see the patient? Yes. Then fire the patient again.
- If a patient has not paid his or her bills, can I refuse to send the patient’s record to another provider? No.
Copyright 2015, Carolyn Buppert
Should I Go Under My Employer’s Malpractice Insurance Coverage Or Get My Own Policy?
Nurse practitioners (NPs) can either purchase their own malpractice insurance or be covered under their employers’ policies. If covered under an employer’s policy, you’ll need to ask some questions to determine whether the coverage is dependable and whether you need to purchase your own policy:
If working for a private practice, and you have been told you are covered under the practice’s policy:
Ask “Am I a named insured?” If the answer is “yes,” ask for a copy of the document for your files. If the answer is “no,” ask how you will be covered if not a named insured.
Ask whether the policy requires any specific supervision of nurse practitioners by physicians.
Ask whether the policy is claims made or occurrence. If claims made, ask how much it would cost you to purchase a “tail.”
Ask for the company’s financial stability rating.
Know that most, if not all, of the companies which insure physicians are owned by physicians. Some of the companies have imposed restrictions on nurse practitioner practice, whereas there were none in the past. Some of these restrictions require physicians to supervise closely, or to be present when the NP is practicing. Some companies have raised rates when a physician employs a nurse practitioner. The companies can make their own rules regarding nurse practitioners, even if those rules “restrict the trade” of nurse practitioners.
If working for a government agency:
Ask whether you are protected under a Tort Claims Act.
If so, ask if there are any conditions under which you could be sued as an individual.
If working for a hospital or large organization
Ask whether the organization purchases a commercial policy or is self-insured
If a commercial policy, ask what the exclusions are; i.e. what are the circumstances under which you would not have coverage.
If the organization self-insures, ask if there are limits to what the organization would pay in the way of damages, attorney fees, and expert witness fees and whether any activities of a NP are not covered.
One cannot know how an insurance company will treat him or her until one is sued, and uses the insurance company’s services. Nurse practitioners who have been sued often don’t talk freely about this experience, so we have little hard or anecdotal data. However, an NP wanting to purchase insurance can get information on three aspects of a company’s product. These are type of coverage (claims made or occurrence), cost and financial stability. Insurance companies’ financial stability are rated by several companies, including A. M. Best.
There are several things NPs can do to sabotage their own planning.
First, if an insurance company offers different rates for pediatric nurse practitioners, family nurse practitioners and adult nurse practitioners, and you are a family nurse practitioner who is only seeing adults, you must purchase the family nurse practitioner coverage, unless you have a written statement from the company agreeing to your purchase of adult nurse practitioner coverage. If you are an FNP but purchase ANP coverage and are sued, the company may decide not to honor your policy, claiming that you misrepresented yourself on your application.
Second, if you are an NP working as an RN, many insurers will tell you to purchase the policy for NPs. If that is their requirement, then that is what you must do.
Third, watch the deadlines for payment.
Copyright 2015, Carolyn Buppert
The Top 10 Must-Do’s for Billing NP Services
Rules on billing are complicated. However, often it is a failure to attend to the basics that causes lost revenues. In order for a nurse practitioner (NP) or physician to receive third-party payment:
The clinician must be enrolled with the payer (Medicare, Medicaid, commercial managed care organization (MCO) or commercial indemnity insurer). The patient’s coverage must be current.
The payer’s rules and process must be followed.
Often, the approval of the designated Primary Care Provider (PCP) must be obtained.
The service must be one that is medically necessary.
The claim must be “clean;” i.e. appropriate CPT (Current Procedural Terminology) and ICD (International Classification of Diseases) codes and correct patient information.
The top 10 things a clinician must attend to, to get paid fairly, are:
- Get credentialed and/or admitted to the provider panel of the organization paying the bill. Medicare and Medicaid authorize NPs to bill for physician services. Some health plans are admitting some NPs to provider panels. Some are not, but allow an NP’s work to be billed under the name of a physician. To get paid, or for an NP’s employer to be paid, an NP needs to either be approved as a provider (have a provider number if the payer is Medicare or Medicaid) or the NP or billing staff must ascertain that the organization will pay the bill if a NP performs the service and it is billed under a physician’s name.
- Ascertain that the patient is covered by a third-party payer, or that the patient agrees to pay the bill himself. Each card from an insurer or health plan has a telephone number for a practice or facility to call to determine whether coverage is current. Each practice should have a system for checking the validity of coverage, and for getting patients to sign a document in which they agree to pay the bill if their coverage is not valid.
- Ascertain that the service the clinician is providing is covered by the patient’s insurance, or that the patient agrees to pay the bill himself. Payers differ, rather significantly, regarding the services they will pay for. For example, virtually all commercial managed care plans pay for preventive visits, but Medicare does not (with a few exceptions). Telephone advice is generally not reimbursed under fee-for-service arrangements. Few, if any, third party payers pay for e-mail advice, but nothing precludes a clinician from charging a patient for e-mail advice, as long as the patient knows he or she must pay the bill and has signed any forms required by the patient’s insurer (for example, an Advance Beneficiary Notice, in the case of Medicare).
- Document a physician service, consistent with the requirements stated in Current Procedural Terminology for the current year and the “Documentation Guidelines for Evaluation and Management,” 1995 or 1997 versions, from the Center for Medicare and Medicaid Services, www.cms.hhs.gov. To avoid a demand for repayment of monies already paid (if audited), meet all of the criteria for billing evaluation and management and document what was done, for each visit. Review the first 35 pages of Current Procedural Terminology for the current year, every year. The elements of evaluation and management are history-taking, examination, medical decision-making, coordination of care, and counseling. At minimum, for an established patient, a clinician must document history and examination with enough detail so that the following criteria are met:
Visit level History Examination Diagnoses Level 1 0 0 1 medical problem Level 2 1 descriptor 1 element 1 medical problem Level 3 1 descriptor, 1 review of systems element 6 elements 2 minor medical problems, or 1 stable chronic illness, or 1 acute uncomplicated illness or injury Level 4 4 descriptors, 2 review of systems elements, 1 element of past, family or social history 12 elements 1 chronic disease with mild exacerbation, or 2 stable chronic illnesses or 1 acute illness with systemic symptoms, or 1 acute complicated injury Level 5 4 descriptors, 10 review of systems elements, 2 elements of past, family or social history 18 elements from 9 body systems 1 chronic illness with severe exacerbation, or 1 illness or injury with threat to life
- Select and include on the claim form, one or more appropriate CPT codes. If a procedure and a significant, separately identifiable evaluation and management service is performed by the same clinician on the same day as the procedure, bill the CPT code for the procedure and use a modifier -25 with the CPT code for the evaluation and management service on the claim form. For example, if performing a joint injection, and it is necessary to examine the extremity before performing the procedure, bill the CPT code for the injection and the CPT code for the E&M service, with -25 added to the CPT code for the E&M service. If the service performed will qualify as both a preventive service and evaluation and management, the clinician may choose to bill one or the other. In this situation, there is nothing wrong with billing the visit for which the reimbursement is best, as long as the service provided fits the CPT code description and the documentation is appropriate.
- Select one or more appropriate ICD codes. Payers insist that clinicians submit an ICD-9 code which indicates the medical necessity of the service performed, and that the ICD code include the appropriate number of digits. For example, for the diagnosis diabetes, include 5 digits. For multiple sclerosis, only 3 digits are required.
- Follow the payer’s rules for billing under a physician’s name, if that is what the practice is doing. Some payers, such as Medicare, allow a practice to bill a service performed by a NP under a physician’s name, and get a higher payment, if certain rules (incident-to rules or shared billing rules) are followed. Some payers will pay for a service performed by a NP but billed under a physician’s name as long as the physician and NP have a contractual or employment relationship. For each payer billed, determine what that payers’ rules are, and follow them.
- Read carefully the terms of any contract a managed care company offers the practice and attempt to negotiate better terms. Once the contract is signed, follow its terms and the accompanying policies and insist that the company follow the contract and its own policies. Sometimes payers don’t follow their own rules. If the payer is Medicare or Medicaid read the rules related to the clinician performing the service, the service, the setting, and the documentation requirements. If Medicare or Medicaid is not following its own rules, call the Provider Relations Office or the Medicare Carrier’s Provider Education Office, explain the situation, and follow the process to appeal or complain.
- If dealing with commercial payers, negotiate a decent fee schedule. If dealing with Medicare and Medicaid, take the time to learn how those fees are set, and the process by which those fees can be raised. Fee schedules may not be fair, but they are negotiable, if one a) asks for a raise, b) explains why the raise is justified, and c) threatens to withdraw something the company wants if they don’t come through with a raise.
- Bill all medically necessary services, drugs and devices. It is easy to forget to bill a medication, the administration of an injection, a urinalysis, or a separately identifiable service performed on the same day as another service. Don’t let money slip through your fingers.
Copyright 2015, Carolyn Buppert
What to Do When Health Plans are Vague About Policies on NPs
Example: Hospital X has nurse practitioners in their emergency room. While some third-party payers, such as Medicare and Medicaid, clearly have policies which call for reimbursement for physician services performed by nurse practitioners, one health plan is difficult to pin down. When the hospital’s billing department submitted bills under a nurse practitioner’s name, the claims were denied. When the billing manager appealed the denial, she was told “We don’t credential nurse practitioners. You can submit the nurse practitioner’s bills under a physician’s name, if the nurse practitioner has a collaborative agreement with the physician.” The billing manager asked for that policy in writing. Two months passed and nothing came. The billing manager asked again, and three months passed, with nothing in writing. The billing manager knows that under Medicare rules, a nurse practitioner’s services must be billed under the nurse practitioner’s name. She worries that the oral policy — “Bill the nurse practitioners’ work under the name of the physician collaborator” — will be impossible to document if the health plan later decides that they follow Medicare’s policy. She is worried that the hospital, and she, individually, will be vulnerable to a charge of fraudulent billing.
For the hospital, the legal issues are:
- If the hospital follows an oral policy — “Bill nurse practitioner services under a physician’s name” — how can the hospital protect its actions if the health plan decides later that it was inappropriate?
- Would the collaborative agreement required by the health plan be the same as the collaborative agreement required by the State? Would the bills need to be submitted under the name of the physician named on the collaborative agreement required by the state?
- Would the physician whose name is on the collaborative agreement need to establish a relationship with each patient?
- Will a hospital policy under which the hospital notifies health plans that nurse practitioners are providing physician services be sufficient to protect the hospital from allegations of fraud?
No law provides a direct answer to these questions. The applicable law includes:
- Nurse practitioners in some states must have collaborative agreement with physicians. In the majority of states, a physician need not be on site, but must be available by radio, telephone or telecommunications. For the law in a specific state, visit the Board of Nursing web site.
- Medicare reimburses physician services when performed by a nurse practitioner, provided the services are within the scope of practice of a nurse practitioner and there is a collaborative agreement with a physician.
- The laws governing reimbursement under Medicare do not necessarily apply to Medicare managed care, as Medicare managed care is governed by a contractual agreement between the Center for Medicare and Medicaid Services (CMS) and the managed care organization (MCO). MCOs delivering care under contracts may include nurse practitioners on their panels, but are not required to do so.
One approach when health plans or MCOs won’t put a policy in writing
It makes little sense for a practice or facility to structure its operation for the least accommodating payer. One approach is to develop a policy regarding how the practice or facility will bill the nurse practitioner’s services, and notify the payers of the policy. For example, in the policy, state something like this:
“Physician services in the emergency department at Hospital X may be performed by a qualified nurse practitioner who is practicing under the authority granted by state law. Services provided by the nurse practitioner will be billed under the nurse practitioner’s name and provider number or under a collaborating physician’s name and provider number, depending upon the requirements of the payer. Hospital X’s Director of Billing will query payers by letter, once, and ask for a response stating their requirements or preference about whether the nurse practitioner’s services are billed under the nurse practitioner’s name or under a collaborating physician’s name. The query letter will state that failure to provide written direction or preference will be assumed to be indifference, and, lacking a response from a payer, the hospital billing department will decide whether to bill the nurse practitioner’s services under the nurse practitioner’s name or under a collaborating physician’s name, depending upon previous written policies or oral communications from the payer.”
Or, a policy may be stated even more broadly, such as:
“Physician services at Hospital X may be provided by qualified nurse practitioners who meet the requirements of state law. Payers who have specific requirements regarding the class of provider under whose name such services are billed must state those requirements, in writing, to Hospital X’s Director of Billing. Lacking written direction from a payer, the Director of Billing will decide whether a nurse practitioner’s services are billed under the nurse practitioner’s name or under the name of a physician on the health plan’s provider panel.”
Then, send the policy to the appropriate contact person at each local health plan or managed care organization, with a cover letter which states “This is the hospital policy. If your organization has specific requirements regarding billing of physician services provided by nurse practitioners, please respond to me, in writing, specifying such requirements, within 15 days. If I do not receive specific written directions from your organization by [insert date], Hospital X will assume that this distinction is not important to your organization, and will bill a nurse practitioner’s services under one of our physician’s names or under the nurse practitioner’s name, if the nurse practitioner is on the health plan’s panel.”
Track and file the responses, and bill accordingly. If there is no response, follow the policy.
Lacking specific directions from a managed care organization, there would be little reason to have a separate collaborative agreements for payers. However, if billing nurse practitioners’ services under one or more physicians’ names, it would be pragmatic to have written documentation of collaborative agreements between the physicians and the nurse practitioners. And, lacking specific directions from a health plan, it makes little sense for the collaborating physician to establish a relationship with patients evaluated and managed by a nurse practitioner, unless required by state law.
Would such a policy, disseminated to health plans, be sufficient to protect the billing administrators from claims of inappropriate billing?
Yes, in the opinion of the author. Fraud is defined as: “An intentional deception or misrepresentation which the individual knows to be false or does not believe to be true, and the individual is aware that the deception could result in some unauthorized benefit to him/herself or some other person.” The hospital in this case is attempting to correctly represent the services being provided, and there would be no deception or misrepresentation.
Copyright 2015, Carolyn Buppert
When Is a Physician Liable for Nurse Practitioner Malpractice?
Consider this case from Illinois:
A woman who had received prenatal care from a nurse practitioner (NP) at a city health clinic gave birth to a child with macrosomia. During delivery, the child sustained a brachial plexus injury, right arm palsy and clawed right hand. Macrosomia and associated birth trauma are related to maternal hyperglycemia.
The mother sued the clinic, the clinic’s doctor, and the clinic’s nurse practitioner, claiming the doctor had never examined her or treated her gestational diabetes and the nurse practitioner had incorrectly advised her that high blood sugar could be ruled out because the patient had a normal urinalysis. (The standard of care for ruling out maternal hyperglycemia is a glucose challenge test followed up with a glucose tolerance test.)
The defendant doctor denied being involved with the mother’s care. He said he became involved in the nurse practitioner’s patients’ care only when the nurse practitioner notified him of a problem, which the nurse practitioner had not done.
The mother’s attorney argued that the defendant doctor was involved with the patient’s care in that the doctor had used his provider number to bill Medicaid, had initialed lab slips, had allowed the nurse practitioner to use his name on prescriptions and had made arrangements to deliver the baby.
The court agreed with the defendant doctor, and he was found not liable in this case. The nurse practitioner settled before the trial for $500,000. The clinic agreed to make payments to the mother. Source: Robinson v. Thomas et al., www.nso.com, and Medical Malpractice Verdicts, Settlements & Experts; Lewis Laska, Editor, 1-800-298-6288.
Now consider this case from North Carolina:
A 36-year-old pregnant patient received prenatal care at a women’s health center from a NP and a MD. On the first prenatal visit, the woman told the NP she would like an amniocentesis. The NP explained that it was a very dangerous procedure and did not refer the woman to anyone to talk about amniocentesis.
Later in her pregnancy, the woman was examined by a MD at the center. The patient again introduced the subject of amniocentesis. The MD asked why she was worried, as 37 years of age was the age where one becomes concerned about Down’s Syndrome. The MD dropped the matter and so did the patient.
After the baby was born, and it was discovered that the baby had Down’s Syndrome, a geneticist took the mother aside and asked whether she had heard of amniocentesis. She said she had discussed it with the physician and he had said it was unnecessary.
The patient sued the NP and MD at the women’s center, claiming they had failed to properly advise the patient with respect to amniocentesis and genetic counseling. The patient claimed that if she had been properly advised she would have had an amniocentesis, it would have revealed that the fetus had Down’s Syndrome, and she would have terminated the pregnancy.
Eventually, liability was assigned to the MD. An appeals held that the MD had breached the standard of care–that at 36-37 years of age, an amniocentesis was indicated if the patient had a high level of concern. The NP was not held liable, because the patient testified at trial that after her conversation with the NP, she still was determined to get the amniocentesis, and that the conversation with the NP did not affect her decision to go for amniocentesis. Source: Azzolino v. Dingfelder, 71 N.C. App. 289, 322 S.E. 2d 567 (1984)
Difference between the facts of these cases as applied to elements of negligence
In order to prove malpractice, a patient must prove four elements of negligence:
- Duty — the clinician has a duty to perform certain acts or interactions after the presumption of a relationship between patient and provider
- Breach of the standard of care
- Injury to the patient
- Causal relationship between the patient’s injury and the provider’s negligence.
The difference in outcome of these two cases is attributable to the first element — duty.
In the first case, the NP was the patient’s provider and the mother never presumed that the MD was the provider, until the mother’s attorney started looking for evidence that would connect the MD with the patient’s care. The trial court did not find that using his provider number to bill Medicaid, initialing lab slips, allowing the NP to use his name on prescriptions and making arrangements to deliver the baby established the MD as a provider and triggered a duty to provide a standard of care to the patient.
In the second case, the MD conducted his own evaluation and management of the patient, in addition to and separate from the NP’s contact with the patient. The NP in the second case most likely would have been found liable, had the patient not testified that her decision to pursue amniocentesis was unaffected by the NP’s failure to refer for the test.
Implications for NPs and their collaborating physicians
Forty-two states require some form of collaboration, supervision or delegation from a physician for an NP to practice. Generally, the malpractice liability and insurance premium of an MD does not increase because the MD has a collaborative relationship with an NP. Actuarial data has shown that the incidence of lawsuits against NPs is lower than the incidence of lawsuits against MDs. Presumably, insurers base premiums on actuarial data, but there is no legal requirement that they do so. Insurers have a wide berth to set whatever premiums they want. So, it probably will not (but may) cost an MD an additional premium to collaborate with a NP. And, an MDâ€™s risk in collaborating with an NP is manageable.
For the purposes of risk management, NP/MD teams may wish to consider the following policies:
- An MD need not co-sign an NP’s note (and is better off not co-signing). Co-signatures provide no value to either NP or MD. Object to any third-party payer whose policy requires a co-signature.
- If an MD meets with an NP’s patient, the MD should assume that he or she is establishing a duty of care to that patient. If, after an NP orally presents a case, an MD recommends a test or treatment, it is not clear that the MD has established a legal duty to the patient, if the MD has never met or talked with the patient. It is arguable that the MD does have a duty to the patient, but there are no recent cases in which an MD was held liable for an NP’s mistake when the MD’s only connection to the patient was an oral presentation from an NP. Likewise, there are no cases in which an MD has been held liable when the NP never consulted the MD, even though the MD was the NP’s “collaborator,” for purposes of meeting state law requirements. Of course, anyone can file a lawsuit against anyone.
- Collaborative arrangements between NPs and MDs are handled most safely if the NP follows the traditional procedures for obtaining consultation or referral. For example, if the NP in the IL case summarized above was unfamiliar with the standard of care for ruling out gestational diabetes, the NP should have referred the patient to the clinic’s obstetrician, who then would have clear responsibility for managing the patient’s care.
Copyright 2015, Carolyn Buppert
Questions answered by Carolyn Buppert on Medscape:
(You may need to register at Medscape.com to access these articles)
New Standard of Care for Prescribing Opioids
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What Can I Do in an Off-Duty Emergency?
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Billing for Nurse Practitioner Services: Guidelines for NPs, Physicians, Employers, and Insurers
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Can I contact my previous patients after starting a new practice?
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How should I pay the physician whose patients I see?
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What are the malpractice needs of physicians who supervise nurse practitioners?
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How does a leased employment agreement work?
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Should I consider a productivity-based salary?
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Can I set up an independent practice providing house calls?
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What Should I Expect When I Renegotiate My Contract?
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What Happens When an Advanced Practice Nurse Is Sued?
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Who Is Responsible if our Billing Is Audited?
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How Do I Bill Commercial Insurers for Palliative Care Consultations?
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How Should We Code Previously Seen patients in Our New Practice?
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