Disclaimer: Practice guidelines provide licensees with general guidance to promote good practice. Law, rules and regulations, not guidelines, specify the requirements for practice and what may constitute professional misconduct
I. Written Practice Protocols & Agreements with Collaborating Physicians
According to New York State Education Law §6902, a nurse practitioner (NP) diagnoses illnesses and physical conditions and performs therapeutic and corrective measures within the specialty area of practice in which the NP is certified. New York certifies NPs to practice in the following specialty areas: Acute Care, Adult Health; College Health; Community Health; Family Health; Gerontology; Holistic Care; Neonatology; Obstetrics; Oncology; Palliative Care; Pediatrics; Perinatology; Psychiatry; School Health; and Women's Health.
New York State Education Law holds nurse ractitioners (NPs) independently responsible for the diagnosis and treatment of their patients and does not require an NP to practice under physician supervision.
Nurse practitioners, however, must practice in accordance with written practice protocols and a written practice agreement with a collaborating physician unless and until the NP has completed 3,600 hours of experience. This experience must consist of practicing as a licensed or certified NP as follows:
- in accordance with the laws of New York or another state, or
- while employed by the United States veteran's administration, the United States armed forces or the Unites States public health service.
Thereafter, the NP may practice independently.
Written Practice Agreements
Nurse practitioners required to have a written collaborative practice agreement must enter into such an agreement with a physician qualified to practice in the NP's specialty area of practice. Written 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 does not 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 State 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. A sample practice agreement can be found at www.op.nysed.gov/prof/nurse/np-sample-collaborative-agreement.pdf. You may use that 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. The Education Law 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 medical director could mediate the dispute and make the final treatment decision. The NP is not legally required to have written collaborative practice agreements with all of the attending physicians.
Written Practice Protocols
Nurse practitioners 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 (e.g., hematology, orthopedics, dermatology) that are appropriate to the NP's practice may be used but need not be reflected in the collaborative practice agreement.
A list of many, but not all recommended Practice Protocols can be found at www.op.nysed.gov/prof/nurse/npapproved.htm.
Form 4NP “Verification of Collaborative Agreement and Practice Protocol”
newly certified NP must file Form 4NP-"Verification of Collaborative Agreement and Practice Protocol" with the Department within 90 days after starting professional practice. This is a one-time filing requirement. A completed Form 4NP is not equivalent to a collaborative practice agreement. Copies of Form 4NP can be downloaded from www.op.nysed.gov/prof/nurse/nurseformsnp.htm.
Note: The Education Law does not require physicians to supervise the NP or to co-sign the NP's orders or medical records. It does require the collaborating physician to review the NP's patient records at least every three months.
II. Financial Arrangements between a Nurse Practitioner and a Collaborating Physician
A variety of New York and federal laws affect financial relationships between health care practitioners. Some types of financial relationships between nurse practitioners 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 State Education Law and regulations prohibit a collaborating physician and an NP from engaging in "fee splitting" or "kick backs." These prohibitions 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) money or other consideration to or from a third party in exchange for the referral of patient services. For example, if a physician pays an 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) a kick back.
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 Law prohibiting fee splitting or kick backs does not prohibit an 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 relationships, collaborative practice agreements, or 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. Please note that the Nursing Board Office does not interpret laws governing financial relationships between NPs and collaborating physicians.