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  • NP in clinic

    I don't want to start another doc vs NP debate

    We have an NP working in our clinic. We see all patients after NP see them and cosign the note. We are in a hospital-employed setting. Lately, the admin is proposing NP see patients independently due to an increase in patient volume. I do not think NP's compensation is based on production and by NP seeing patients independently physicians won't be getting their RVUs. As per the state rules, 10 percent of the charts need to be reviewed and signed by physicians. There is no extra compensation to supervise NP. I think physicians are taking more responsibilities without getting any extra compensation by allowing NP to see patients independently. Any ideas in using NP in the clinic in a way that is beneficial for the employed physicians?
    How does malpractice claims work in case NP gets sued by a patient who was not seen by a physician? Do they always go after the supervising physician even if they didn't see the patient or cosign the chart?

    Thanks in advance

  • #2
    Originally posted by randumdoctor View Post
    I don't want to start another doc vs NP debate
    Good luck with that.

    I wish I had some useful input for you.

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    • #3
      Unfortunately, this is the direction things have been going for a while (at least for primary care in my area). It's all about the hospital system generating the same revenue but paying you less.

      My health system reimburses something like $6k per year to supervise an NP/PA, which is obviously a pittance compared to their production.

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      • #4
        The only theoretical advantage in that type of scenario that I’ve found is if the docs are overwhelmed/busy the NPs can offload some of the low reimbursing work (procedure follow ups) to allow the doc to crank through the more important stuff (new patients).., or if you’re in a specialty where NPs can generate ancillary services (stress tests) or procedures (caths) for the doc.

        But if you don’t control the NPs and they answer to their admin bosses and not you, then. It’s unlikely that all three players (doc, np, admin) will be on the same page of what the goals of the NP truly are.

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        • #5
          Originally posted by randumdoctor View Post
          How does malpractice claims work in case NP gets sued by a patient who was not seen by a physician? Do they always go after the supervising physician even if they didn't see the patient or cosign the chart?

          Thanks in advance
          it depends

          if a doc cosigns the chart (some do it sight unseen - not a good idea imho) then heck yes you are liable and the NP provides no shield whatsoever, you are both accused of malpractice.

          if you had the chance to see the patient although NP was independent and chose not to, could go either way, you'd probably be just fine. this is like when an NP is working in a fast track and you can see the board but don't see every patient. this does not apply when an APP is doing consults for your urology group.

          if the NP is deciding which pts to present to you and choses not to do so you are fine, although they are probably in even more trouble b/c they had a doc available and chose not to present case.

          i think the NP vs. doc thing is much more clear in litigation than it is on internet forums, APPs are expected to access physicians when they have questions and the "well i'm an independent provider" stuff is probably harmful to them in that situation. to me it's just a jury thing, most people understand that even a DNP is not a physician and the plaintiffs attorney can hammer on "why didn't you talk to a doctor?"

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          • #6
            Aren’t np malpractice premiums very low? I’d be concerned that it’s just being made up on the physician side

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            • #7
              Not sure what specialty you are but I'm outpatient family practice. Our nps work independently have their own panel and see their own patients. They generally see far less than the physicians and usually shy away from the more complicated things. Really it does not offer us any benefit other than someone to help cover when we're out or offload some of the work when it gets real busy. But it has not impacted me in much of a negative way yet. A ratio is pretty good with more docs than NPS at this point.

              In an ideal world I would have the mid levels doing the most mundane parts of my job. Taking care of messages and labs and follow up radiology reports. Few visits here and there too justify their income after my schedule is packed. But unfortunately it is not an ideal world and I do not call the shots.
              Last edited by Lordosis; 02-13-2022, 10:08 AM.

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              • #8
                I'm in an independent practice State. I'm hospital employed and in clinic we have a few NPs who basically do a little of everything for us, including seeing easy follow-ups. All on their own and bill on their own too. We are not involved at all nor in any supervisory role on those particular visits. We're there if they have questions. We don't take credit for their rvu. I'm a little confused what responsibilities or supervision you'd have to provide your NPs. Whether that's a hospital rule or State rule. I'd imagine for malpractice our NPs are on their own and it's the hospital's responsibility. As for that 10% rule, I'd imagine you'd work it out with your hospital but maybe see those patients with NP and get credit for it.

                Honestly, NP's would benefit me most by taking care of the bs low-yield things. Messages, paperwork, insurance, easy follow ups or needy patients, etc. Our few NPs and other staff help with that but I still do a bunch on my own and it's an inefficient, annoying use of my time. Seeing patients is the easy part.

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                • #9
                  In my previous hospital-employed job, our NPs work independently but we have to cosign all of their notes despite not ever seeing or discussing about these patients. I never felt comfortable due the potential liability but sucked it up because I didn't have a choice. The hopsital wasn't going to change the way they operate. This is one of reasons I enjoy my current job much more.
                  In surgical/procedural speciality, NPs can be very helpful in generating procedure referrals and seeing follow-ups. Our NPs also see less complicated cases and help relieve the referral volume, sometimes to the dissatisfaction of our referring providers but this is how the system works.

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                  • #10
                    Tough situation

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                    • #11
                      Fyi I’m employed Family medicineby a big organization,… I learned recently that there was a Family medicinenurse practitioner making 180 K per year base while seeing 10 to 12 patients per day…

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                      • #12
                        we have to cosign all of their notes despite not ever seeing or discussing about these patients

                        Do you have to do this ?

                        Why would you ever sign a contract that states this?

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                        • #13
                          In my experience, work contracts with large hospital system are often short and standardized contracts. Rarely do I see this kind of detailed information included in the contract. Of course I can discuss all of the patients prior to signing but when you have a full day at work, often at a different site from where the midlevel practices, how likely will you have time to discuss all of the cases after hours. This kind of practice and cosigning notes vary from state to state, and even within a state, it varies on how the hospital system set up the system of oversight and negotiate billing for midlevels. AMA has a good summary of scope of practice for all NPs/PAs per state level. Something to think about when looking for jobs.

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                          • #14
                            Originally posted by Savedfpdoc View Post
                            Fyi I’m employed Family medicineby a big organization,… I learned recently that there was a Family medicinenurse practitioner making 180 K per year base while seeing 10 to 12 patients per day…
                            That is 100% absurd. I’m not sure that our new primary care docs make much more than that salary guarantee for the first two years, and certainly expect to build to 20-22/day.

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                            • #15
                              Originally posted by Savedfpdoc View Post
                              Fyi I’m employed Family medicineby a big organization,… I learned recently that there was a Family medicinenurse practitioner making 180 K per year base while seeing 10 to 12 patients per day…
                              im really confused why an organization would ever pay that when there are so, so many NPs around

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