I would like to know if any of you are seeing this trend where physicians are hiring registered nurses to function in the capacity of an Advanced practice nurse. I know of several situations where a registered nurse is hired by a provider to round on patients and write orders as if they were advanced practice clinicians when in reality they are not.
Please respond with input or personal experience with this problem
I never sign an RX. I work from protocols or algorithms for medications administered in a clinic. Narcotics are strictly off limits, written or oral to call into pharmacies in my state by anyone other than a physician. I would love for the MD to come in to assess the patient, and make his own decisions. But the MD is not usually present. I'm lucky I can get him to sign all his orders when I see him because he is so rushed at times. APRN are not hired for practice where I work. I would love an APRN to make rounds. Most of the APRN that I have met work in the large university hospitals. It does sound like blurring of the scope of practice which may happen more than we want to think. I have personally visited some outpatient clinics and observed the administration of meds by medical assistants and I question if they are even checking the vials carefully. It appears that management of healthcare cost is resulting in blurring of the lines or scope of practice as someone stated in an earlier post.
Then you've never seen our facility's protocols. And I agree that this is outside the scope of MAs. For my argument, I'm talking specifically about RNs, treating common and uncomplicated infections, using their facilities protocols and algorithms, which are backed by research and published evidence.
I haven't seen them, true, but I think most would agree that protocols do not tend to favor the individual but rather the disease. That is the medical model in a nutshell. I am not sure I understand your rationale that it is out of the scope of MAs but in the scope of RNs? If the protocol/algorithm is perfect then what shouldn't any HCP be able to use it, or for that matter any lay person? Why not have a web form that patients fill out and a computer decides the outcome based on the protocol? Theoretically a computer wold be even better and have less bias.
And how do you know that the infection is common? And how do you know it's uncomplicated?
80% of UTIs are caused by E. Coli, which in almost all cases, is susceptible to nitrofurantoin. It's a safe med, and its use in uncomplicated UTIs is recommended by the literature. They even recommend that a culture is not indicated unless Sx are not resolved with the prescribed med.
Our local resistance here is actually about 15%. Generally it is a relatively safe and effective med when used in the correct way; it can also be less safe and less effective if used inappropriately.
I never sign an RX. I work from protocols or algorithms for medications administered in a clinic. Narcotics are strictly off limits, written or oral to call into pharmacies in my state by anyone other than a physician. I would love for the MD to come in to assess the patient, and make his own decisions. But the MD is not usually present. I'm lucky I can get him to sign all his orders when I see him because he is so rushed at times. APRN are not hired for practice where I work. I would love an APRN to make rounds. Most of the APRN that I have met work in the large university hospitals. It does sound like blurring of the scope of practice which may happen more than we want to think. I have personally visited some outpatient clinics and observed the administration of meds by medical assistants and I question if they are even checking the vials carefully. It appears that management of healthcare cost is resulting in blurring of the lines or scope of practice as someone stated in an earlier post.
I honestly think that this is fraudulent....because I can guarantee they are billed as being under the care of a physician.... When clearly they are not
Specializes in Nurse Leader specializing in Labor & Delivery.
I am not sure I understand your rationale that it is out of the scope of MAs but in the scope of RNs? If the protocol/algorithm is perfect then what shouldn't any HCP be able to use it, or for that matter any lay person?
Our facility policy and many state BONs states that it is outside the scope of UAP to assess patients.
And how do you know that the infection is common? And how do you know it's uncomplicated?
I don't understand what you're asking in the bolded. As far as uncomplicated - our facility algorithm determines that - is the patient female? Is she pregnant? Has she been treated for another UTI in the past 2 months? Does she have any comorbidities such as DM? Have her sx been occurring for more than 7 days? Does she have flank pain or fever?
It's really not rocket science. The algorithm was approved by our medical director, based on current literature. We even have a nurse triage line and they can use the algorithm to send an Rx to the patient's pharmacy, without even collecting a urine culture or physically assessing the patient!!!eleven!
Specializes in Nurse Leader specializing in Labor & Delivery.
I'm sure they write it and sign it for them just like when you get a verbal order...... Seems a bit out of the scope of practice
But I was referring to literal physical prescriptions that are handed to the patient. I assume Roser was not, because I do not see how a physician could sign a written script after the fact, if it's already given to the patient.
Specializes in Nurse Leader specializing in Labor & Delivery.
I honestly think that this is fraudulent....because I can guarantee they are billed as being under the care of a physician.... When clearly they are not
No, you can't guarantee that they are fraudulently being billed as a physician visit.
Our facility offers vaccine clinics, where the patient sees nobody but the MA. The nurses have their own patient schedule each day, where patients come in to see the nurse only and does not see a LIP. We do not bill the provider or put anything on the superbill which would suggest that the patient saw a physician or APRN. We have specific codes that indicate it's an "RN Only" visit, or "vaccine only" visit.
And yes, our MAs are able to administer certain medications on the order of the provider with whom they're working. For those visits, yes, the PROVIDER is seen and is billed. The MA just administers the medication after the provider has assessed the patient.
No, you can't guarantee that they are fraudulently being billed as a physician visit.
Our facility offers vaccine clinics, where the patient sees nobody but the MA. The nurses have their own patient schedule each day, where patients come in to see the nurse only and does not see a LIP. We do not bill the provider or put anything on the superbill which would suggest that the patient saw a physician or APRN. We have specific codes that indicate it's an "RN Only" visit, or "vaccine only" visit.
And yes, our MAs are able to administer certain medications on the order of the provider with whom they're working. For those visits, yes, the PROVIDER is seen and is billed. The MA just administers the medication after the provider has assessed the patient.
That is very different than what is being described...... And it's concerning to me that you are unable to differentiate
Our facility policy and many state BONs states that it is outside the scope of UAP to assess patients.
I don't understand what you're asking in the bolded. As far as uncomplicated - our facility algorithm determines that - is the patient female? Is she pregnant? Has she been treated for another UTI in the past 2 months? Does she have any comorbidities such as DM? Have her sx been occurring for more than 7 days? Does she have flank pain or fever?
It's really not rocket science. The algorithm was approved by our medical director, based on current literature. We even have a nurse triage line and they can use the algorithm to send an Rx to the patient's pharmacy, without even collecting a urine culture or physically assessing the patient!!!eleven!
It sounds like the algorithm is assessing the patient, diagnosing, and prescribing.
Diagnosing and treating a UTI is not rocket science, for the majority of patients, but for a minority of patients it is also not as simple as plugging a few answers into an algorithm. That's just comes from experience in the provider role and the fact I wouldn't want my family members being treated solely by an algorithm. Sure it saves time for providers but is it good for the patients?
That is very different than what is being described...... And it's concerning to me that you are unable to differentiate
A 99211 level E&M code can be billed without a provider seeing the patient, provided a licensed provider is on the premises to bill incident-to under, and it can be used for MAs or LPNs/RNs. Essentially they are "under the care" of the incident-to provider but it doesn't not need to be via direct intervention by that provider.
If they are not on-premesis, then that would/could be fraud.
A 99211 level E&M code can be billed without a provider seeing the patient, provided a licensed provider is on the premises to bill incident-to under, and it can be used for MAs or LPNs/RNs. Essentially they are "under the care" of the incident-to provider but it doesn't not need to be via direct intervention by that provider.
If they are not on-premesis, then that would/could be fraud.
evolvingrn, BSN, RN
1,035 Posts
I'm sure they write it and sign it for them just like when you get a verbal order...... Seems a bit out of the scope of practice