California NP's - Scope of Practice Advice

[amalay, MSN, RN]

Hello fellow NPs!

I am currently about 6 months into my first position as a PNP in an outpatient clinic out in California (Dignity Health, for those who are familiar). It's a large organization, similar to that of Sutter Health or Kaiser. In the organization as a whole, there are only about 10 midlevel providers and only about 2-3 NPs, perhaps 5-6 including the nurse midwives as well.

I work in the pediatric office, and I'm the only NP on board. I've been told that they have had NPs in the practice in the past but so far it doesn't seem like anyone in the organization or facility is very familiar with my scope of practice. I have contacted my clinic manager and medical director multiple times but haven't gotten a response...and I just wanted to run a few quick questions by other NPs:

1) Are we allowed to open notes under our own names? So far, I am the ONLY midlevel provider that is being told to open chart notes in the EMR under my supervising physician's name...or another physician that is on site. There HAVE been days where there is no other MD on site (on call, in the hospital) and no one knows what to do with my notes at that point. I have ALWAYS opened notes under my own name in the past, so this is creating a lot of confusion both for myself and the support staff.

2) Do physicians have to physically cosign all my notes? I was under the impression that they needed to review 20% of my notes, but not necessarily cosign.

3) Are we allowed to be listed as a PCP in the provider panel? Most of the patients I see get assigned to one of the physicians, even though they've only been seeing me as their primary.

Thanks for any input. Any advice on who else I can contact to help me advocate for myself? I don't seem to be getting anywhere with administration at work...

[Corey Narry, MSN, RN, NP]

Hi there, fellow California NP here. I hear you, it must be hard navigating the logistics of your practice as a new NP and as the sole non-physician provider in the clinic. California as a state is actually listed by AANP as one of 12 states with restrictive practice (the only western state in the list). There are two important aspects of our work that you must know by heart to survive and remain compliant in practice: (1) State Scope of Practice and (2) Billing.

I look at California Scope of Practice for NP's and summarize it in two words - Standardized Procedures. This is a document that forms the basis of what you can and can not do as a nurse practitioner. It is a document that per California law, must be mutually agreed upon by the healthcare institution that you work under, the physician who "supervises", and you as the NP. The first step is to read what your standardized procedures state. There is no explicit requirement that a specific number of charts (20%) are reviewed but your standardized procedure probably state that. Similarly, the co-signing of notes may be an institutional requirement built in to your standardized procedure. An explanation of Standardized Procedure is available here.

The other part that you must know about is billing. You work in Pediatrics where majority of patients either have private insurance or Medi-Cal. Private insurances have various rules for empaneling an NP as a PCP and this is an issue that you can only resolve with individual companies. However, Medi-Cal (the state Medicaid program) has explicit rules for enrollment of NP's and you can even be listed as an independent PCP with Medi-Cal (if you're a PNP or FNP). See: Medi-Cal Enrollment of Non-Physician Medical Practitioners.

With Medi-Cal you either bill as an independent PCP (under certain rules) or as part of a physician-led team. I am assuming you are billing under the latter which does require physician supervision. For this to be legal, there must be a physician who is available to supervise you as outlined in your standardized procedure. There is no requirement for physicians to co-sign your notes to bill.

Having said all that, I do see issues with how you're practice is set-up. I don't like the fact that you are not logging into the EMR to open your notes under your name. I feel like this is fraud. I would bring this up as a concern and maybe even volunteer to run it by risk management or the billing department at your institution to review if you're compliant with the rules. Present it to the physicians as not "rocking the boat" but just making sure the practice is not going to be in trouble from the regulatory bodies.

I think Dignity Health as a system is large enough to have the resources to help you even though they don't have many NP's. BTW, I'm familiar with that system, it used to be known as Catholic Healthcare West.

[amalay, MSN, RN]

Thank you so much Juan for your detailed response. I have to agree with you that I have always thought that it was odd I am being told I can't open up notes under my own name. I have checked and all the other PAs and NPs in the organization have notes under their own names...I'm not sure what exactly got miscommunicated with me.

Another issue of concern though: I never signed a document of standardized procedures when I first started the job. I have contacted my medical director regarding having one in place and have asked to see a copy but I have yet to receive a response. Is there anyone else I can contact to help me with this matter? I have thought about contacting other NPs in the organization to ask but I'm not sure that that will be effective or very professional if I went around a supervisor/administrators back to ask around.

[core0]

Thank you so much Juan for your detailed response. I have to agree with you that I have always thought that it was odd I am being told I can't open up notes under my own name. I have checked and all the other PAs and NPs in the organization have notes under their own names...I'm not sure what exactly got miscommunicated with me.

Another issue of concern though: I never signed a document of standardized procedures when I first started the job. I have contacted my medical director regarding having one in place and have asked to see a copy but I have yet to receive a response. Is there anyone else I can contact to help me with this matter? I have thought about contacting other NPs in the organization to ask but I'm not sure that that will be effective or very professional if I went around a supervisor/administrators back to ask around.

With a large organization there should be two departments that can help you here. The first is credentialing. They should be doing the paperwork for licensure and making sure everyone is following the rules for licensure. Ask them for your standard procedures, just tell them that you never got a copy. That should stir them into action if they forgot.

The other department is compliance. If you don't get any help from your department go to them and tell them what's happening. Couch in terms of you want to make sure you are doing things correctly. If you use terms like documenting under another persons name, that usually makes steam come out of their ears. They should be able to provide guidance.

[amalay, MSN, RN]

Thank you so much for your response. Thankfully, I recently was able to resolve the whole "not being able to open my own notes" issue at a meeting with my medical director. I didn't have a chance to bring up the standard procedures document though since it was a general meeting and I didn't want to bring up such a individualized/personal issue in front of everybody. I will try to contact the credentialing department to follow-up-- although when I asked for contact info for the credentialing department, I was told to contact the administrative assistant for the director instead. Fishy that they can't just give me the e-mail of who I want to contact?