Nurse practitioner's business practice and legal guide / Carolyn Buppert.

Includes bibliographical references and index.

Table of Contents

Preface.............................................. ix
Chapter 1 What Is a Nurse Practitioner?................... 1
Definition of Nurse Practitioner ................. 1
A Nurse Practitioner, by Any Other Name............ 2
Services Provided by NPs ...................... 3
Preparation and License Requirements............ 5
Initials .................................... 6
Areas of Practice............................. 6
Legal History of NPs.......................... 6
Demographics .............................. 7
NPs in Primary Care.......................... 7
NP versus PA: What's the Difference?.............. 11
NP versus Physician: What's the Difference?........ 13
NP versus RN: What's the Difference?............. 15
NP versus CNS: What's the Difference?............ 16
Where Do Nurse Practitioners Practice?............ 18
Appendix 1-A: State-by-State Definitions of
Nurse Practitioner .......................... 19
Appendix 1-B: State-by-State Titles for
Nurse Practitioners ......................... 36

Chapter 2 Legal Scope of Nurse Practitioner Practice......... 39
Professional Association Definition of Scope of Practice................................ 39
Statutory versus Regulatory Scope of NP Practice..... 40
Physician Challenges to NPs' Scope of Practice...... 41
Need for Clarity of Scope of Practice.............. 41
NP Scope of Practice Compared with RN Scope of Practice................................ 42
NP and MD Scope of Practice Compared........... 46
Mandated Physician Involvement with NP Practice... 47
Appendix 2-A: State Laws Defining NPs' Scope of Practice, State by State....................... 50
Appendix 2-B: State-by-State Requirement of Physician Collaboration, If Any ................ 76

Chapter 3 State Regulation of Nurse Practitioner Practice..... 104
How Laws about NP Practice Evolve.............. 104
What Is Regulated? ........................... 105
Appendix 3-A: Agency That Regulates Nurse
Practitioners, State by State................... 107
Appendix 3-B: Nurse Practitioner Qualifications
Required by Law, State by State................ 110
Chapter 4 Federal Regulation of the Nurse Practitioner
Profession ............................... 125
Medicare .................................. 125
Medicaid .................................. 129
Nursing Homes ............................. 129
In-Office and Hospital Laboratories under CLIA...... 130
Self-Referral by Health Care Providers, under the
Stark Acts ................................ 130
Prescription of Controlled Substances under the DEA. 131
Reporting to the National Practitioner Data Bank..... 132
Patient Confidentiality ........................ 132
Discrimination in Hiring and Firing............... 132
People with Disabilities under the ADA............ 132
Appendix 4-A: Documentation Guidelines for
Evaluation and Management Services ........... 134
Chapter 5 Prescribing ................................ 170
Controlled Substances ........................ 170
Guidelines for Prescribing Legally................ 174
Appendix 5-A: State-by-State Law on Prescriptive
Authority ................................. 176

Chapter 6 Hospital Privileges........................... 208
Are Hospital Privileges an Issue for NPs?........... 208
Do PCPs Need Hospital Privileges?............... 209
What If Health Plans Require PCPs To Have Admitting Privileges? ........................ 210
Do NPs Need Hospital Privileges for Advancement
of the Profession? .......................... 210
Do Individual NPs Need Hospital Privileges?........ 211
Who Has Hospital Privileges? ................... 212
Does Federal Law Support Full Hospital Privileges for NPs? ................................. 213
What Does It Mean To Have Hospital Privileges?..... 214
Levels of Privilege............................ 214
The Application Process ....................... 214
Expense ................................... 215
Denial of Privileges........................... 215
Expect Change .............................. 216

Chapter 7 Negligence and Malpractice.................... 217
What Can Happen to an NP Who Is Sued?.......... 218
Life Cycle of a Lawsuit......................... 219
What Is Malpractice?.......................... 219
Elements of Malpractice ....................... 220
Examples of Lawsuits against NPs................ 221
The National Practitioner Data Bank.............. 226
Working with Practice Guidelines................ 227
How To Prevent Lawsuits...................... 228
What To Do If Sued........................... 228
Communication ............................. 228
Liability of Collaborating Physicians.............. 229
Malpractice Insurance ........................ 231

Chapter 8 Risk Management ........................... 233
Risk of Making a Clinical Error................... 233
Risk of Being Sued for Malpractice When There
Was No Clinical Error ....................... 237
Risk of Public Perception That the Individual NP Is a Poor-Quality Provider.................... 237
Risk of Breaching Patient Confidentiality........... 237
Risk of Violating a Patient's Right to Informed Consent ................................. 238
Risk of Negligent Nondisclosure ................. 243
Risk of Poor Quality Ratings.................... 245
Risk of Disciplinary Action ..................... 245
Risk of Medicare Fraud........................ 247
Business Risk Management..................... 248
Dealing with High-Risk Patients ................. 249

Chapter 9 Reimbursement for Nurse Practitioner Services..... 252
Payers .................................... 252
Medicare .................................. 252
Medicaid .................................. 256
Indemnity Insurers ........................... 257
Managed-Care Organizations ................... 257
Direct Contracts for Health Services.............. 262
Billing Third-Party Payers ...................... 262
Billing Self-Paying Patients ..................... 268
Conclusion ................................. 269
Appendix 9-A: Credentialing Information .......... 270

Chapter 10 The Employed Nurse Practitioner ............... 273
What Rights Does an Employed NP Have?.......... 273
Does an NP Need a Contract?................... 274
Three Difficult Clauses ........................ 275
How To Negotiate a Reasonable Agreement......... 281
Interviewing ................................ 287
Responsibilities of an NP Employee............... 288
Employer's Evaluation of the NP's Performance......
288 Malpractice Insurance ........................ 289
Collaborative Practice Agreements ............... 289
Appendix 10-A: Sample Nurse Practitioner
Consultation Practice Agreement............... 290
Appendix 10-B: Sample Employment Agreement..... 295

Chapter 11 Practice Ownership: Legal and Business
Considerations for the Nurse Practitioner Owner.. 306
Advantages of Practice Ownership................ 306
What Is Stopping NPs? ........................ 307
Decisions before Starting a Practice............... 308
Business Planning............................ 324
Doing Business.............................. 330
Appendix 11-A: A Checklist for Setting Up a Practice.. 345
Appendix 11-B: Independent Contractor Agreement.. 360
Appendix 11-C: Sample Business Plan............. 365
Appendix 11-D: Professional Services Agreement .... 382

Chapter 12 Lawmaking and Health Policy.................. 389
The Legal Process............................ 389
The Judicial System........................... 390
Health Policy ............................... 391
Laws and Rules That Affect NPs.................. 391
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Table of Contents vii
Changing Laws .............................. 391
Understanding the Big Picture................... 392
The Process of Changing the Law................ 398
Conclusion ................................. 406

Chapter 13 Promoting the Profession to the Public........... 407
Public Relations Steps......................... 408
Setting the Goal ............................. 408
Developing the Plan .......................... 408
Developing the Budget ........................ 409
Working the Plan ............................ 409
The Substance of the Message................... 410
Supporting Data ............................. 411
Collecting Impressive Facts..................... 413
Present Barriers to Fact Collection................ 414
Not-So-Impressive Facts about NPs............... 414
Dealing with the Downside..................... 415
Appendix 13-A: A Simple PR Plan for a State NP
Organization .............................. 418
Appendix 13-B: Some Talking Points for NPs........
421 Appendix 13-C: Sample Fact Sheets on NPs......... 424

Chapter 14 Standards of Care for Nurse Practitioner Practice... 428
Definitions of Standard of Care.................. 428
Who Is Monitoring Standard of Care?............. 428
How Should NPs Keep Current on Standard of Care?..
442 Credentialing ............................... 442

Chapter 15 Measuring Nurse Practitioner Performance........ 444
Measuring Quality ........................... 444
Multiple Measures, Multiple Measurers............ 445
Productivity ................................ 446
Housekeeping Performance Measures............. 447
NCQA Measures of Clinical Performance........... 447
Other Measures ............................. 449
Formal Research............................. 450
Patient Ratings .............................. 450
Peer Review ................................ 451
Utilization ................................. 451
How To Get an "A" on Performance Report Cards.... 451
Ensuring Compliance ......................... 452
Appendix 15-A: NPs' Self Evaluation.............. 455
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viii NURSE PRACTITIONER'S BUSINESS PRACTICE AND LEGAL GUIDE
Appendix 15-B: HEDIS-Based Health Maintenance
Flowchart for Ages 18 and Over................ 456

Chapter 16 Strategies for Advancing the Profession........... 458
Opportunities in a Changing Field................ 458
Opponents of a See-a-Nurse-First System.......... 459
What Are the Challenges for NPs Attempting To Advance the Profession? ..................... 460 Strategies To Implement Collectively.............. 461 Ten Strategies............................... 461