help me work through this problem…

[AKMD_1984]

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MD anesthesia/ pain here with 50-50 practice - i work as an independent contractor.

i’m in texas.

one of the clinics i work for 1/2 day a week decided to hire NPs without my input 3 months into my contract. i am not the medical director of the clinic. i dont have any equity nor any say in billing etc. i am paid on fee schedule.

however they are asking me to be the delegating physician. they’re paying me a few bucks per month for that. kinda suspect…why isn’t the actual Medical director doing that

it’s not a high risk practice - we don’t rx opioids as it’s a personal injury practice. it’s not a medicare practice but of course we want to abide by guidelines and best practices.

however this said np is 100% remote. have never met her. never evaluated her skills. don’t have her cv either. we have had usual zoom meetings - more so in the beginning and if course if there are issues she texts or calls me

this was never clarified. i show up in person to do my clinic.

my biggest issue in all this is that there is no physical exam being performed and heavy reliance on mri findings and history only for decisions on injections….

i’ve been reviewing her charts….seems like there’s a lot of nonsense and things that an experienced NP or FP would never do

part of the issue is that she doesn’t have any training in pain … she has done functional medicine and integrative lifestyle stuff…

honestly the risk for delegating this np isn’t worth it

worse yet they asked me “if i will be charging extra for another part time np that they’re brining on” lmao….

i guess i have never really done np delegation as i am a md only practice (both anesthesia and pain - i dont employ any crnas either). i’m just not a big fan…but the np does do a lot of initial intake evaluations and starts the pt on non narcotic meds which is helpful to me.

what should be the approach here?

my signed agreement with them does say that i agree to delegate np but doesn’t go into detail about quality, experience, and risk of a specific individual. secondly i thought that whoever they hire will be in person in clinic. i’m not a fan of remote only and work from home arrangements.

those of you delegating to np ‘s- are you making them go through any courses and certifications? if so which ones?

 

[drusso]

MD anesthesia/ pain here with 50-50 practice - i work as an independent contractor.

i’m in texas.

one of the clinics i work for 1/2 day a week decided to hire NPs without my input 3 months into my contract. i am not the medical director of the clinic. i dont have any equity nor any say in billing etc. i am paid on fee schedule.

however they are asking me to be the delegating physician. they’re paying me a few bucks per month for that. kinda suspect…why isn’t the actual Medical director doing that

it’s not a high risk practice - we don’t rx opioids as it’s a personal injury practice. it’s not a medicare practice but of course we want to abide by guidelines and best practices.

however this said np is 100% remote. have never met her. never evaluated her skills. don’t have her cv either. we have had usual zoom meetings - more so in the beginning and if course if there are issues she texts or calls me

this was never clarified. i show up in person to do my clinic.

my biggest issue in all this is that there is no physical exam being performed and heavy reliance on mri findings and history only for decisions on injections….

i’ve been reviewing her charts….seems like there’s a lot of nonsense and things that an experienced NP or FP would never do

part of the issue is that she doesn’t have any training in pain … she has done functional medicine and integrative lifestyle stuff…

honestly the risk for delegating this np isn’t worth it

worse yet they asked me “if i will be charging extra for another part time np that they’re brining on” lmao….

i guess i have never really done np delegation as i am a md only practice (both anesthesia and pain - i dont employ any crnas either). i’m just not a big fan…but the np does do a lot of initial intake evaluations and starts the pt on non narcotic meds which is helpful to me.

what should be the approach here?

my signed agreement with them does say that i agree to delegate np but doesn’t go into detail about quality, experience, and risk of a specific individual. secondly i thought that whoever they hire will be in person in clinic. i’m not a fan of remote only and work from home arrangements.

those of you delegating to np ‘s- are you making them go through any courses and certifications? if so which ones?

You are right to be uncomfortable. This is how liability quietly shifts to the person whose license is on the delegation paperwork.

If you are not the medical director, have no ownership, do not control billing, and have never trained or vetted the NP, you are essentially receiving a nominal fee to absorb someone else’s risk. That is not genuine delegation. It is liability transfer disguised as “collaboration.”

In Texas, delegation requires a genuine supervisory relationship. You are expected to know the NP’s competency, review charts, and ensure that care meets accepted standards. Doing that for someone you have never met who is working remotely with minimal pain training is professionally indefensible if something goes wrong.

I would either refuse to delegate or create a separate agreement that defines your role, sets clear clinical boundaries, and compensates you appropriately for the risk. The “few bucks a month” arrangement is not enough to justify signing off on decisions you cannot meaningfully oversee.

When delegation is done correctly, NPs complete formal pain management training through organizations such as ASRA or AAPM, maintain collaboration logs, and participate in structured chart reviews. Anything less than that is an accident waiting to happen.

They are asking you to take responsibility for people and processes you do not control, and that is a hard no in my book.

 

[SSdoc33]

agree with drusso.

you are assuming the risk of the NP. this was basically forced upon you without your consent. if you take on the risk, you should be paid for it. handsomely.

 

[IYKYK]

An NP doing telemedicine for PI with patients in pain is a recipe for disaster. They are going to miss acute injuries because they aren't doing exams. Even if they don't, there's a huge risk to your reputation. If you get deposed, the lawyer will certainly ask about the physical exam and paint you to be the greedy doctor doing injections on patients just because they pay more for PI.

Side note, I DM'd you. I'd love to learn more about your current practice set up.

 

[hyperalgesia]

Your discomfort is why you're the MD and why the state of Texas gives you supervisory authority.

 

[AKMD_1984]

You are right to be uncomfortable. This is how liability quietly shifts to the person whose license is on the delegation paperwork.

If you are not the medical director, have no ownership, do not control billing, and have never trained or vetted the NP, you are essentially receiving a nominal fee to absorb someone else’s risk. That is not genuine delegation. It is liability transfer disguised as “collaboration.”

In Texas, delegation requires a genuine supervisory relationship. You are expected to know the NP’s competency, review charts, and ensure that care meets accepted standards. Doing that for someone you have never met who is working remotely with minimal pain training is professionally indefensible if something goes wrong.

I would either refuse to delegate or create a separate agreement that defines your role, sets clear clinical boundaries, and compensates you appropriately for the risk. The “few bucks a month” arrangement is not enough to justify signing off on decisions you cannot meaningfully oversee.

When delegation is done correctly, NPs complete formal pain management training through organizations such as ASRA or AAPM, maintain collaboration logs, and participate in structured chart reviews. Anything less than that is an accident waiting to happen.

They are asking you to take responsibility for people and processes you do not control, and that is a hard no in my book.

thank you sir. it doesn’t pass the sniff test for me.

thank you for sharing those resources. i’ll take a look

 

[AKMD_1984]

Your discomfort is why you're the MD and why the state of Texas gives you supervisory authority.

yeah…honestly as i enter mid career im of the belief less is more
less aggressive treatments, less hands in things…i just want to only be responsible for my work … cut the noise…
part of me feels that i got played here and im more upset about that than anything

should have really investigated the extent of their intentions but i honestly didn’t expect or anticipate it

essentially they’re billing for new pt and follow up visits by having np see the pt and paying her instead of me

the correct course of action should have been in hire, fire, bring on a midlevel and train them and also sign off on their work

 

[Agast]

What are you going to do about it?

 

[AKMD_1984]

What are you going to do about it?

term the current cintract with an offer of how i feel it should be done

take it or leave it

i’d rather do anesthesia anyways

 

[geauxg8rs]

Is this a chiro run clinic? Is that who decided this?

 

[SgtThunderfistMD]

You are working at a "personal injury practice". How could you be surprised about it being a highly unscrupulous practice?

 

[AKMD_1984]

You are working at a "personal injury practice". How could you be surprised about it being a highly unscrupulous practice?

Hi

I will try to answer this in a mature manner since you’re making a lot of sweeping statements here. Yes it is true that many PI practices can be unscrupulous.
So can chronic pain practices be. Drugs for blocks and excessive procedures etc and facility fee games, etc etc.

I do not care for others or answer to others as I am only responsible for my own conduct and choices.
However, I believe that ESIs and TFESIs for acute HNP and cervical MBBs for whiplash are excellent procedures in conjunction with PT and non narcotics for acutely injured patients. Forget the legal aspect and funding companies and who’s holding the bill. I am talking about science and experience here.

Axial LBP - i feel LMBBs work well but not quite as well as CMBBs. I follow Dr Bogduk’s protocol and manual.

If those injections fail, I refer to surgeon. I do not keep a patient for more than 4 months without a ortho or surgeon consult; allowing them to chime in.

That’s briefly how I practice and it’s independent of who owns the practice. Chiro can be greedy yes - but so can be other pain docs, PE and many others who exploit our license and credentials.

Those above listed injections are 85% of my interventional practice along with joint injections. I like to think that I am practicing in an ethical manner, irrespective of who owns it. My relationship is with the patient.

My setup is fee schedule based without ownership or equity. It is truly contractor dependent. I do not care for or discriminate to do million injections because half the time I do anesthesia and I enjoy that quite well.

PI was attractive to me schedule wise because I could keep up with my skills and pain cases without the big production that is required in chronic pain. I also have a building and an insurance based clinic but I’ll be honest with you - I have not seen the same ROI on it because basic medications are rejected by insurance companies. It’s growing slowly but it takes time to build a high quality practice. I’m in that phase.

 

[BobBarker]

I don’t have much of a problem with your PI practice. I don’t like the lawyers also acting as a bank but that model exists here too.



But if you have an independent pain practice, there is no way basic meds should be rejected by insurance. Medicare doesn’t like to pay for muscle relaxers due to fall risk, but they are very inexpensive if the patient pays for them. That is the only example I can think of. I would make sure that you aren’t making simple mistakes. Don’t prescribe tizanidine capsules or 5mg cyclobezaprine, only 10mg.


If you make a different thread about what issues you are facing in your private practice, we can help you. I make much more money than any anesthesiologist does in the operating room.