Collaborative Practice Agreements for Telehealth NPs and MDs

Supervisory relationships are a necessary step for nurse practitioners wanting to work in virtual care across many state lines. Learn more about the physician-np collaborative practice agreement and how to safely, and compliantly, set one up.

Within the last decade, the nurse practitioner workforce has more than doubled, a response to the industry’s increasing focus on primary care and a growing physician shortage. While most NP employment is concentrated in hospitals, physicians offices, and outpatient care centers, the explosion of more accessible and affordable virtual care has prompted significant opportunities for NPs to work in telehealth.

While virtual care employment opportunities are plentiful, the laws regulating independent NP practice have not adapted to our current care delivery models and greater NP utilization across state lines.

In order for clinicians to access a consistent flow of virtual care consults, it’s often necessary to garner multiple state licenses. But for NPs, practice authority varies from state to state, with some states allowing treatment and prescribing with independent authority, and others limiting the NP’s practice through mandatory physician oversight and collaboration, through what’s known as collaborative practice agreements.

For nurse practitioners seeking multi-state licensure or physicians interested in collaborating with a nurse practitioner, navigating the regulatory landscape and state-by-state supervision rules can be overwhelming.

Here we outline the ins and outs of collaborative practice agreements for NPs and the key protections in place for MDs and DOs who wish to sponsor an NP.

Why do I need a collaborative practice agreement?

In order to practice medicine with full authority to evaluate, diagnose, provide treatment, and prescribe medication, many states require some degree of physician supervision for nurse practitioners. The level of supervision required varies by state, from regular in-person meetings to chart review quotas to prescription/protocol review, and can be a temporary requirement prior to gaining full-practice authority (three years, a specific number of clinical hours) or an ongoing requirement for state licensure.

Particularly within a virtual care practice, where it’s beneficial to hold multiple state licenses, a nurse practitioner will likely need to engage in a collaborative agreement in order to deliver care in a specific state.

What is a collaborative practice agreement?

A collaborative practice agreement is a written contract that establishes a working relationship between the nurse practitioner and the physician. Often this means that the physician will provide supervision and guidance, and be available for consultations with the NP. Some states may require regular face-to-face meetings or set a chart review quota.

States generally have three levels of practice authority for NPs:

• Full practice: The nurse practitioner may work without supervision and provide clinical care including evaluating and diagnosing patients, ordering and interpreting tests, initiating and managing treatment, and prescribing medications.

• Reduced practice: The nurse practitioner can provide certain services independently, and must have a collaborative agreement with a physician for other elements of patient care.

• Restricted practice: The nurse practitioner is restricted from engaging in one or more elements of clinical practice, and supervision by a physician is required for patient care.

Collaborative practice agreements should include the activities that fall within the individual NP’s scope of practice including: types of services that can be rendered, types of medical conditions that can be treated, which services and conditions require physician consultation, whether the NP can order perform or interpret lab tests, X-rays, or EKGs, and whether the NP can prescribe and manage medications.

What states require physician oversight?

Regulations requiring collaborative agreements vary from state to state and have been changing frequently due to the pandemic. Consult the board of nursing in your desired states to verify current requirements and scope of practice limitations.

How do NPs find a physician collaborator?

Word of mouth is often one of the best ways to find a collaborative relationship. Many nurse practitioners find physician collaborators through colleague referrals and other work connections, posting inquiries on social media groups, participating in in-person and virtual industry events, joining networking groups, and making connections through LinkedIn.

Once you find a collaborator, you’ll need to formalize your relationship in writing with a collaboration agreement. Many state nursing boards or state professional nursing associations can provide collaboration agreement templates.

The role of the collaborating physician

While the exact requirements of a collaborative relationship vary by state, some level of physician involvement or supervision is required in order for the NP to provide clinical care.

Physician services can include consulting with the NP and answering questions, chart review, making medical diagnoses, ordering diagnostic tests, and prescribing medications.

The physician is typically paid an hourly rate, a set annual fee, or some combination of the two. The amount the physician is compensated depends on the time commitment and specific requirements of the agreement.

Risk and protection for collaborating physicians

Many collaborating physicians are concerned about liability. After all, if a nurse practitioner makes a mistake and is sued for malpractice, the physician supervising them could be sued as well.

Overall, the liability exposure for a collaborating physician is similar to that of any healthcare provider or executive who oversees other clinicians. Many states exempt collaborating physicians from liability for the actions of their partner NPs, or are ambiguous about whether the collaborating physician could be liable in these circumstances.

However, there are a few states in which collaborating physicians are held liable for the actions of their supervisee NP.

To protect against liability, collaborating physicians should secure three layers of coverage.

• Professional Liability: covers bodily injury, technology errors and omissions, product failures, intellectual property rights infringement and defamation for all professional services performed by the clinician.

• Cyber and Privacy Liability: covers network security and privacy liability, regulatory costs and fines, incident response costs, and legal, forensic and breach management costs.

• Director and Officer (D&O): covers any other non-indemnifiable loss resulting from a claim based on a wrongful act by the insured person.

In addition to the supervisory responsibilities as dictated by the state board of nursing, physician collaborators should regularly review patient charts for quality assurance purposes and, perhaps most importantly, develop an open channel of communication with the supervised NP.

Successfully working in telehealth as an NP

Nurse practitioners providing virtual care need to know that, depending on where they practice and what services they provide, they may need physician oversight to treat patients. Laws vary, so it’s important to make sure you’re in compliance with the regulations in your state. By finding a collaborating physician, setting up a collaborative practice agreement, and making sure the physician has appropriate liability protection, NPs will be well positioned to set up a successful virtual practice.

Interested in working in virtual care as a physician or nurse practitioner? Learn more about Wheel’s opportunities for virtual care clinicians.