Compensation for collaboration with nurse practitioner

[notlucid]

I have a question regarding expected compensation for collaboration with nurse practitioner. What is the common practice.

I worked in the past in a national organisation where no compensation was provided.If you worked there, only the time for discussion,one hour was blocked each month. Another job I worked at, the psychiatrist who did this was paid 5k a year. I have heard numbers of 20 percent of collections to 5k per year.

Also what is liability in this case for records not reviewed.
This is for a state with no written requirement except an agreement that collaboration is there.
Health department says as long as formal discussion happens it is ok.
Malpractice Insurance company says monthly record review.
I am doing monthly written record reviews 15 charts a month and providing feedback. This takes 6 to 8 hours a month.
Thanks in advance.

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[dl2dp2]

There's no standard here and practices are highly variable. In general, I think percent billing for a collaborative agreement is a bad idea, reason being that this essentially imposes an additional tax on the person being billed, disincentivize their working more. Furthermore, typically this kind of work doesn't linearly scale--reviewing 15 charts often don't take much more time than reviewing 10 charts so you are introducing a progressive tax.

I think of this as a private consultation opportunity for private quality assurance. Bill by the hour of your clinical hourly rate (maybe tag on another 10/20% for value-add), have them file a 1099. Try for a few months to determine how many hours you really need, and go from there. If institutions want you to do this for free, refuse. It's HIGHLY unlikely they'll fire you for this.

As for malpractice standards, it's also very variable. Cases for NPs that reach supervising attendings are rare, especially in outpatient, and very rare in psychiatry, so there's no case law for guidance. I would say if you are committed to do this you should feel comfortable that all of the NP cases are covered to standard of care level. Maybe not as high of a level as your personal patients, but it shouldn't drop below acceptable community standard.

 

[TexasPhysician]

In my state, there is a minimum, but the board believes the minimum should occur only after years of practicing together (knowing their style). They will punish physicians under “inappropriate supervision” even though it isn’t written. Initially, all charts should be reviewed and signed with weekly education and 24/7 availability for questions.

Your license is 100% on the line. A NP started prescribing opiates in a friend’s psych clinic. Reviewing more than the minimum (not by much) was not enough to catch this NP. The board ruled that the psychiatrist was a danger to society due to inappropriate supervision and pulled his license. He did show that he supervised above the minimum written requirement. He has been unable to win an appeal or get licensed elsewhere. He is currently a real estate agent.

If I were to do this, I’d require $5k/month or more to cover weekly reviews, education, call, and increased liability. I’ve seen people get this rate and more.

 

[Merely]

In my state, there is a minimum, but the board believes the minimum should occur only after years of practicing together (knowing their style). They will punish physicians under “inappropriate supervision” even though it isn’t written. Initially, all charts should be reviewed and signed with weekly education and 24/7 availability for questions.

Your license is 100% on the line. A NP started prescribing opiates in a friend’s psych clinic. Reviewing more than the minimum (not by much) was not enough to catch this NP. The board ruled that the psychiatrist was a danger to society due to inappropriate supervision and pulled his license. He did show that he supervised above the minimum written requirement. He has been unable to win an appeal or get licensed elsewhere. He is currently a real estate agent.

If I were to do this, I’d require $5k/month or more to cover weekly reviews, education, call, and increased liability. I’ve seen people get this rate and more.

That seems unusually harsh..damn

 

[TexasPhysician]

That seems unusually harsh..damn

I thought so too, but opiates are in the spotlight these days. Medical boards like sending a message, and they are usually made up of fairly strict folk. Nursing boards not so much in my experience.

 

[notlucid]

I think collaboration/supervision is state dependent. 5k/year was considered generous in Midwest.

 

[whopper]

Cases for NPs that reach supervising attendings are rare, especially in outpatient, and very rare in psychiatry, so there's no case law for guidance. I would say if you are committed to do this you should feel comfortable that all of the NP cases are covered to standard of care level. Maybe not as high of a level as your personal patients, but it shouldn't drop below acceptable community standard.

The very reason why I don't want to touch NPs with a 10 foot pole.

I worked with one once, against my judgment, cause someone in the private practice (not the current one I work at but a prior one) kept pushing it so I promised him to at least give it a try. I asked the NP for the legal groundwork on what happens if the dung hits the fan. She didn't know. I asked the state medical board--> they didn't know. She requested information from her alma mater, they didn't know.

I've had a lot of patients where I'm looking at their records or during the interview and thinking "WTF?" over some pretty bad practice and when I ask the patient did they address it they often times tell me they tell their NP who then does nothing, and when they try to communicate with the MD in charge of the NP the MD doesn't listen and tells them to talk to the NP. (e.g. BP consistently around 170/100 and there's nothing done with the BP meds, a cholesterol of 290 and again nothing is done--> even for years).

Same happens with MDs. I see bad practice there too, but for both the NP and the MD to blow off the patient just makes me more mad cause they had 2 chances and blew both of them to get the patient better, and it just smacks to me of an MD just trying to make money assembly-line style, with pushing patients in and out. Why? The very fact that he hired an NP, that he/she's not apparently providing enough supervision, and that MD when he/she had the chance blew it too, a bad NP will become apparent to any MD with half a brain within months, so at that point he/she needs to act and either get rid oft that NP or otherwise step-up their game.

 

[Sushirolls]

5K just isn't worth it. You can moonlight 2 weekends some place and get that much without any additional worries or hassles. Remember, NP education is less than a physician who is about to start a Residency. PGY-0 has more training and more experience.

 

[whopper]

I have seen one excellent NP and I'm sure there's great NPs out there but the legal infrastructure for their use (or lack thereof....) makes this a NO for me.

 

[dl2dp2]

In my state, there is a minimum, but the board believes the minimum should occur only after years of practicing together (knowing their style). They will punish physicians under “inappropriate supervision” even though it isn’t written. Initially, all charts should be reviewed and signed with weekly education and 24/7 availability for questions.

Your license is 100% on the line. A NP started prescribing opiates in a friend’s psych clinic. Reviewing more than the minimum (not by much) was not enough to catch this NP. The board ruled that the psychiatrist was a danger to society due to inappropriate supervision and pulled his license. He did show that he supervised above the minimum written requirement. He has been unable to win an appeal or get licensed elsewhere. He is currently a real estate agent.

If I were to do this, I’d require $5k/month or more to cover weekly reviews, education, call, and increased liability. I’ve seen people get this rate and more.

Damn!! Good to know!!!

 

[Merely]

I thought so too, but opiates are in the spotlight these days. Medical boards like sending a message, and they are usually made up of fairly strict folk. Nursing boards not so much in my experience.

How does one get on a medical board? Is it volunteer?

 

[TexasPhysician]

How does one get on a medical board? Is it volunteer?

Political appointment is my understanding. In my state, 1/3 of the members are not even physicians.

 

[DisorderedDoc417]

5K just isn't worth it. You can moonlight 2 weekends some place and get that much without any additional worries or hassles. Remember, NP education is less than a physician who is about to start a Residency. PGY-0 has more training and more experience.

One weekend.

 

[deleted480308]

You aren’t collaborating

 

[PikminOC]

1 million dollars

 

[WisNeuro]

Political appointment is my understanding. In my state, 1/3 of the members are not even physicians.

Same here for the Med and Psychology boards. State bylaws mandate that X number of board positions are by non-physician/psychologist members. Probably a good thing as long as it's kept in the clear minority.

 

[notlucid]

Many times collaboration is part of job requirement.In states with independent practice, are there no requirements?
I am thinking of asking 1 day a month for record review for supervision of 2 NP's, If I have to do it. That would be approx 10k/year/NP. Any suggestions ?

 

[TexasPhysician]

Many times collaboration is part of job requirement.In states with independent practice, are there no requirements?
I am thinking of asking 1 day a month for record review for supervision of 2 NP's, If I have to do it. That would be approx 10k/year/NP. Any suggestions ?

Hard pass. Not enough money for huge liability and associated responsibilities that could effect your license. If you are reviewing the charts, anything they do at all is now an extension of you.

 

[dl2dp2]

Many times collaboration is part of job requirement.In states with independent practice, are there no requirements?
I am thinking of asking 1 day a month for record review for supervision of 2 NP's, If I have to do it. That would be approx 10k/year/NP. Any suggestions ?

10k a year for 1 day a month seems REALLY low. 8*200*12 = $19200. And people are paying telepsychiatry $200 an hour so this is def on the low side for this kind of work. I would start by asking for 50k, and see if you can really circumscribed it to 1 day a month.

Also, just FYI, I know people who run this kind of practice. NPs make about 100-150k a year. 30-40% on top of that is net profit--this is for an MD run practice who directly supervises his own NPs. So they generate the practice at minimum 50k a year. It's not unreasonable to get a 50% cut of that profit for providing a high level of oversight. The owners provide no value here--they don't supervise and they don't take liability, and merely provide logistic cost sharing.

 

[notlucid]

Thank you.
I was basing it on 20 to 30 chart reviews for 2 NP's for 1 days a month = 20k/2 = 10 k per practitioner. But that gives a starting point.
It is mostly medicaid population.I really like my job.
I just dont like the part of collaboration as the prior arrangement was no formal arrangement and no compensation.