Collaborative Practice with Physicians
Source & Date: New York State Nursing Board Office - February, 2013
According to New York State Education Law §6902, a nurse practitioner (NP) diagnoses illnesses and physical conditions and performs therapeutic and corrective measures within a specialty area of practice. This law requires the NP to practice in collaboration with a physician qualified to collaborate in the NP’s specialty area of practice, and in accordance with a written practice agreement and written practice protocols.
New York State Education Law does not require a physician to supervise an NP or to co-sign any of the NP’s orders, records or charts. New York Law holds NPs independently responsible for the diagnosis and treatment of their patients. An NP is not legally allowed to perform any nursing service that the NP is not personally competent to perform.
Each nurse practitioner (NP) must enter into a written collaborative agreement with a physician in order to practice. Collaborative practice agreements include provisions addressing:
- Patient referral and consultation.
- Coverage for emergency absences of either the NP or the collaborating physician.
- Resolution of disagreements between the NP and the collaborating physician regarding diagnosis and treatment. If the agreement doesn’t address this, the collaborating physician’s diagnosis or treatment shall prevail.
- Peer review by the collaborating physician of patient records in a timely fashion, but no less often than every 3 months. New York Law does not specify the number of charts that must be reviewed by the collaborating physician. That decision is left to the judgment of the NP and collaborating physician, and may vary depending on such factors as: the NP’s experience, the collaborating physician’s knowledge of the NP’s abilities, the population to be served and the practice setting.
- Identification of written practice protocols that the NP will use.
- Additional provisions as agreed to by the NP and the collaborating physician.
A copy of the collaborative practice agreement must be kept at the NP’s practice setting(s) and made available for inspection by the New York State Education Department (SED). Here is a copy of a sample collaborative agreement ( 20 KB) that you may use as a model.
Many NPs work for 2 or more health care providers or at a facility with patients who are being cared for by several different physicians. SED does not necessarily require that the NP to enter into multiple collaborative agreements in such situations. For example:
- If an OB-GYN NP works at an obstetrician’s practice 3 days a week and at Planned Parenthood for 2 days a week, the NP could enter into a collaborative practice agreement with the obstetrician. The collaborative practice agreement could identify a physician (other than the obstetrician) at Planned Parenthood to review the charts of the NP’s Planned Parenthood patients, or, alternatively, the obstetrician could review the NP’s charts at Planned Parenthood. The NP is not required to enter into a second collaborative agreement.
- If an NP works in a nursing home, the medical director may serve as the collaborating physician. In case of a disagreement between the NP and an attending physician, the collaborating physician could mediate the dispute and make the final treatment decision. It is not required that the NP has collaborative agreements with all of the attending physicians.
Nurse practitioners (NPs) are required to practice pursuant to written protocols reflecting the specialty area(s) of practice in which the NP is certified. The protocols must also reflect current, accepted medical and nursing practice. Additional protocols in subspecialty areas (i.e., hematology, orthopedics, dermatology) that are appropriate to the NP’s practice may be used but need not be reflected in the collaborative practice agreement.
For a list of many, but not all, recommended Practice Protocols, click here.
Newly certified nurse practitioners (NPs) are required to file with the New York State Education Department (SED) Form 4NP-“Verification of Collaborative Agreement and Practice Protocol” within 90 days after starting professional practice. The NP is not required to file any additional Form 4NPs with SED. A completed Form 4NP is not equivalent to a collaborative practice agreement. Form 4NPs can be downloaded from SED’s website by clicking here.
There are variety of New York and federal laws that affect financial relationships between health care practitioners. Some types financial relationships between nurse practitioners (NPs) and collaborating physicians are prohibited by the Education Law or professional misconduct regulations (See, e.g., Education Law § 6513, 8 NYCRR § 29.1) or other state or federal laws.
New York Education Law and professional misconduct regulations prohibit a collaborating physician and an NP from engaging in “fee-splitting” or “kick-backs”. These legal prohibitions on “fee-splitting” and “kick backs” are designed to ensure that medical and nursing decisions are based on sound clinical judgment, uncompromised by economic or business considerations.
A “kick-back” typically occurs when a person gives or receives or agrees to give or receive any money or other consideration to or from a third party in exchange for the referral of patient services. For example, if a physician pays a NP $100 each and every time the NP refers a patient to the physician for medical care, then it is very likely that the physician is giving and the NP is receiving “kick-backs”.
“Fee splitting” can occur if an NP shares his or her practice income or fees with a physician who is not the NP’s employer. “Fee splitting” also includes arrangements or agreements in which the NP pays the collaborating physician an amount of money that constitutes a percentage of, or is otherwise dependent upon the income or receipts of the NP in exchange for the collaborating physician’s services. For example, if an NP pays 20% of the NP’s professional income to the collaborating physician (who works at a separate medical practice) in exchange for the collaborating physician’s services, the NP and the physician are probably engaging in illegal “fee splitting”.
The Education Laws prohibiting “fee-splitting” or “kick-backs” do not prohibit a NP from paying a collaborating physician the fair market value of the physician’s personal services (i.e., chart review and consultation), unless:
- the payment includes remuneration for the referral of patient services;
- the NP is required to refer patients to the physician; or
- the payment is based on a percentage of or dependent on the NP’s professional fees or income.
NPs may refer patients to their collaborating physicians when medically necessary, provided that the NP receives nothing in exchange for the referral. New York law does not require that a collaboration agreement include a payment provision.
Questions about collaborative practice agreements and practice protocols may be referred to the Nursing Board Office by e-mailing firstname.lastname@example.org or by calling 518-474-3817 ext. 120, or by faxing 518-474-3706. It is not within the purview of the Nursing Board Office to interpret laws governing financial relationships between NPs and collaborating physicians.