Nurse Practitioner Practice Authority

According to the American Medical Association (AMA), physician involvement of nurse practitioners is required for diagnosis and treatment. The AMA identifies the nurse practitioner practice authority for all 50 states and the District of Columbia.

Cal. Bus. & Prof. Code §2835.7, according to the AMA, defines a nurse practitioner as an RN (registered nurse)

“Who possesses additional preparation and skills in physical diagnosis, psychosocial assessment, and management of health-illness needs in primary health care, and who has been prepared in a program conforms to board standards as specified in Section 1484. (16 Code Cal. Rules 1480 (a)).”

In addition to any other criteria, standardized procedures may be implemented that authorize an NP to do any of the following:

(1) Order Durable Medical Equipment.

(2) In collaboration with a physician and surgeon – and after the performance of a physical examination by the nurse practitioner – certify that a patient has a disability as defined by Section 2708 of the Unemployment Insurance Code.

(3) “For individuals receiving home health services or personal care services, after consultation with the treating physician and surgeon; approve, sign, modify, or add to a plan of treatment or plan of care.”

A “standardized procedure” is the legal mechanism for RNs and NPs to perform functions that would otherwise be considered the “practice of medicine.” To use standardized procedures, an organized healthcare system must collaboratively (by agreement) develop standardized procedures with the system’s nursing, medicine, and administration departments. Standardized procedure functions “are the diagnosing, prescribing, and severing or penetrating of tissue functions under the ‘MPA’.”

The standardized agreement should clarify:

• When a nurse must obtain a second opinion
• What limitations on the standardized procedure apply
• What education the nurse must have to utilize the standardized procedure
• The settings where standardized procedures can be used
• How the standardized procedure will be evaluated

What are collaborative agreements?

A few of the key points that medical practitioners and practices should understand about “collaborative agreements” are the following:

• State requirements. Each state, such as California, determines the necessity and terms of nurse practitioner (NP) practice agreements (called collaborative agreements). Essentially, collaborative agreements “define the scope of medical care provided by NPs in collaboration with licensed physicians.”
• Medicare requirements. Medicare may also require collaborative agreements (even in states with “full practice” environments to obtain reimbursement. Hospitals may also mandate the use of collaborative agreements to control their liability and oversight requirements – especially where NPs can prescribe medications.

According to The Intake, California (in part due to the COVID-19 pandemic) began to relax the “regulatory requirements on NPs, including temporarily waiving certain supervisory requirements.” As the country emerges from the pandemic, the opportunities for NPs to expand their medical care duties are still continuing due to an ongoing national physician shortage.

In California, and most other states, collaborative agreements/practice agreements will continue to play a role in how NPs perform their duties.

Additional California’s NP considerations

California also has different NP categories with different restrictive practice obligations. According to the California Board of Registered Nursing, these two new nurse practitioner categories permit NPs to “function within a defined scope of practice without standardized procedures.”

• “103 NP – Works under the provisions outlined in Business and Profession Code Section 2837.103. This NP must work in a group setting with at least one physician and surgeon.”
• “104 NP – Works under the provisions outlined in Business and Professions Code Section 2837.104. This NP may work independently within the population focus of their National Certification.”

What doctors and NPs should know about collaborative agreements

A collaborative agreement is a contract between the collaborating physicians and NPs to expand the medical services NPs can provide.

Physicians and NPs should understand the different types of medical practices and their state’s collaborative agreement requirements for each type of practice. According to the American Association of Nurse Practitioners (AANP), NP medical care is regulated as follows:

• Full practice states. In these states (such as New York, New Mexico, Colorado, and Washington) all NPs can:
  • “Evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing.”
• Restricted practice states. In these states (such as California, Michigan, Florida, and Texas),
  • “State law requires a career-long regulated collaborative agreement with another health provider in order for the NP to provide patient care or state law limits the setting of one or more elements of NP practice.”
• Reduced practice states. In these states (such as Pennsylvania, Louisiana, Indiana, Ohio, and Illinois), the NP must have a regulated collaborative agreement with another health provider to provide patient care. “State law requires career-long supervision, delegation, or team management by another health provider in order for the NP to provide patient care.”

Practice agreements and Medicare requirements

The Medicare Regulations state that:

“Medicare Part B covers nurse practitioners’ services in all settings in both rural and urban areas, only if the services would be covered if furnished by a physician and the nurse practitioner … Performs them while working in collaboration with a physician. [Emphasis added]. Collaboration under Medicare is defined as ‘a process by which the nurse practitioner has a relationship with one or more physicians to deliver health care services’.”

This means that even in full-practice states, an NP will need to execute a collaborative/practice agreement in order for the NP to receive reimbursement from Medicare.

Hospitals, long-term care facilities, and other institutions may also require collaborative agreements for other reasons.

Many states, like California, permit nurse practitioners to provide some patient care – provided that there is a collaborative agreement (also known as a practice agreement) between the NP and a medical practice or medical institution that sets forth the specific criteria for providing patient care.

Physicians and nurse practitioners should contact Cohen Healthcare Law Group, PC to discuss their regulatory compliance requirements. Our experienced healthcare attorneys advise medical professionals about healthcare compliance laws and regulations.