Hiring a certified registered nurse practitioner

By Dennis Hursh, Esq

Hiring a certified registered nurse practitioner (CRNP) can prove to be very rewarding for physician practices, by effectively “extending” the ability of a physician to see patients during regular hours, and to provide coverage during non-office hours. However, a physician must be aware of the parameters of the physician-CRNP relationship before determining if a CRNP is right for his or her practice.

Hiring a CRNP is not like hiring another physician. The CRNP requires supervision by a licensed physician, and must serve under the direction of a specified licensed physician. Specifically, a licensed physician must be immediately available through direct communications or radio, telephone or telecommunications. A predetermined plan for emergency services must be jointly developed by the supervising physician and the CRNP. Finally, a physician must be available on a regularly scheduled basis for referrals, review of the standards of medical practice of the CRNP (including consultation and chart review), establishing and updating standing orders and drug and other medical protocols within the medical setting, periodic updating in medical diagnosis and therapeutics, and co-signing when necessary to document accountability by both parties.

Unless a waiver is obtained from the State Board of Nursing and the State Board of Medicine, a physician may not supervise more than four CRNPs who prescribe and dispense drugs at any one time. The regulations promulgated by the State Board of Medicine provide an example of the application of this restriction, and state that a physician may supervise four CRNPs who prescribe drugs in the morning and four other CRNPs in the afternoon. A collaborative agreement (discussed below) must be in place between the supervising physician and each prescribing CRNP.

A collaborative agreement is the signed written agreement between a supervising physician and the CRNP in which they agree to the details of the collaborative arrangement between them with respect to the care of CRNP patients. The regulations specify ten requirements of a collaborative agreement between a physician and a CRNP who will prescribe drugs:

· Identify the parties, including the collaborating physician, the CRNP and a substitute physician who will provide collaboration and direction for up to 30 days if the collaborating physician is unavailable.

· Identify the area of practice in which the CRNP is certified.

· Identify the categories of drugs from which the CRNP may prescribe or dispense.

· Contain attestation by the collaborating physician that the physician has knowledge and experience with any drug that the CRNP will prescribe.

· Specify the circumstances and how often the collaborating physician will personally see the patient, based on the type of practice, sites of service and condition of the patient, whether the treatment is for an ongoing or new condition, and whether the patient is new or continuing.

· Specify the conditions under which the CRNP may prescribe a Schedule II controlled substance for up to 72 hours.

· Be kept at the primary practice location of the CRNP and a copy filed with the Bureau of Professional and Occupational Affairs.

· Be made available for inspection to anyone seeking to confirm the scope of practice of the CRNP.

· Be updated by the collaborating physician and the CRNP whenever it is changed substantively.

· Specify the amount of professional liability insurance carried by the CRNP.

Some practices require (or desire) specific unique provisions in the collaborative agreement. However, many practices find that a comprehensive employment agreement, combined with the sample collaborate agreement found in the Application for CRNP Prescriptive Authority on the State Board of Nursing’s website are adequate for their purposes.

Because of the confidential nature of the CRNP’s employment agreement with respect to salary and other matters, the author does not recommend attempting to include employment provisions within a collaborative agreement.

A CRNP may not prescribe or dispense gold compounds, heavy metal antagonists, radioactive agents or oxytocics. However, the following categories of drugs may be prescribed if relevant to the area of practice of the CRNP:

· Antihistamines.

· Anti-infective agents.

· Antineoplastic agents, unclassified therapeutic agents, devices and pharmaceutical aids if originally prescribed by the collaborating physician and approved by the collaborating physician for ongoing therapy.

· Autonomic drugs.

· Blood formation, coagulation and anticoagulation drugs, and thrombolytic and antithrombolytic agents.

· Cardiovascular drugs.

· Central nervous system agents, (except general anesthetics and monoamine oxidase inhibitors).

· Contraceptives including foams and devices.

· Diagnostic agents.

· Disinfectants for agents used on objects other than skin.

· Electrolytic, caloric and water balance.

· Enzymes.

· Antitussive, expectorants and mucolytic agents.

· Gastrointestinal drugs.

· Local anesthetics.

· Eye, ear, nose and throat preparations.

· Serums, toxoids and vaccines.

· Skin and mucous membrane agents.

· Smooth muscle relaxants.

· Vitamins.

· Hormones and synthetic substitutes.

The prescription blank of the CRNP should contain the certification number of the CRNP, the name of the CRNP in printed format, and a space for the entry of the DEA registration number, if appropriate. In addition, the collaborating physician should also be identified on the CRNP’s prescription blanks.

The prescriptive authority of CRNPs is not unlimited. Specifically, a CRNP may only write a prescription for a Schedule II controlled substance for up to a 72 hour dose. The CRNP is then required to notify the collaborating physician as soon as possible, but in no event longer than 24 hours after writing the prescription. In addition, a CRNP may prescribe a Schedule III or IV controlled substance for up to 30 days. However, this prescription will not be subject to refills unless the collaborating physician authorizes refills for that prescription.

In addition, a CRNP may not prescribe or dispense a Schedule I controlled substance, or prescribe or dispense a drug for use not approved by the FDA, without the approval of the collaborating physician. The prescriptive authority which is specifically assigned to the CRNP by the collaborating physician may not be delegated to any other health care provider by the CRNP.

Many physician practices utilize CRNPs to see patients in the office on an equal basis with physicians. There is no regulatory impediment to doing so, so long as the other legal requirements as set forth above are met. However, the CRNP regulations do require that the patient be notified at the time of making an appointment that he or she will be seen by a CRNP (as opposed to a physician). Because of the close relationship many CRNPs are able to develop with the patients of the practice, many practices impose a covenant not to compete upon the CRNP as part of the employment relationship.

As is the case with most activities of a physician practice, the hiring of a CRNP is highly regulated, and competent legal counsel should be consulted before finalizing any arrangement. However, notwithstanding the complexities inherent in the employment of a CRNP, many physician practices find that the ability to serve more patients and to devote CRNP time to “routine” tasks can be financially rewarding. With the proper CRNP, patient satisfaction can also be increased by increasing the time spent with a health care professional by these patients. Therefore, if done correctly, employment of CRNP can be a “win-win” situation for the practice and its patients.

Dennis Hursh, Esq., is a principal in Hursh & Hursh, P.C., a Middletown, Pennsylvania law firm concentrating on representation of physicians and physician group practices.