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What type of professional relationship is currently required by New York State law for Nurse Practitioners in practice?

What type of professional relationship is currently required by New York State law for Nurse Practitioners in practice?

What type of professional relationship is currently required by New York State law for Nurse Practitioners in practice?
QUESTION
What type of professional relationship is currently required by New York State law for Nurse Practitioners in practice? How is this relationship formed and sustained?
What type of professional relationship is currently required by New York State law for Nurse Practitioners in practice?

ANSWER
I. Collaborative Work
A nurse practitioner (NP), according to New York State Education Law 6902, diagnoses illnesses and physical conditions and performs therapeutic and corrective measures within the specialty area of practice in which the NP is certified. Adult Health; Family Health; Gerontology; Neonatology; Obstetrics; Oncology; Pediatrics, Perinatology; Psychiatry; School Health; Women’s Health; Holistic; and Palliative Care are the specialty areas in which NPs are certified in New York.

The New York State Education Law holds NPs independently responsible for their patients’ diagnosis and treatment and does not require an NP to practice under physician supervision. This law requires each NP to practice in accordance with written practice protocols and a written practice agreement with a collaborating physician, as described in greater detail below. An NP with more than 3600 hours of qualifying NP practice experience, on the other hand, can choose to:

Continue to practice in accordance with written practice protocols and a written practice agreement with a collaborating physician, as described in Section II “Practicing in Accordance with a Written Practice Agreement with a Collaborating Physician,” below; or practice and have collaborative relationships with one or more qualified physicians or a New York State Health Department licensed health care facility (i.e., hospital, nursing home, ambulatory surgery center, or diagnostic imaging facility).
II. Adherence to a Written Practice Agreement with a Collaborating Physician
Unless the NP practices and has collaborative relationships as allowed by law and as described in more detail in Section III, “Collaborative Relationships,” below, New York State Education Law requires all nurse practitioners (NPs) to practice in accordance with written practice protocols and a written practice agreement with a collaborating physician.

This section explains the specific requirements of the New York State Education Law for practicing in accordance with written practice protocols and a written practice agreement with a collaborating physician. The NP must collaborate with a physician who is qualified to collaborate in the NP’s specialty area of practice, according to the law. The NP must follow written practice protocols as well as a written practice agreement with the collaborating physician.

Practice Agreements in Writing
A nurse practitioner (NP) must enter into a written collaborative practice agreement with a physician qualified to practice in the NP’s specialty area of practice in order to practice. Provisions in written collaborative practice agreements address:

Referral and consultation of patients
Coverage for either the NP’s or the collaborating physician’s emergency absences.
Disagreements between the NP and the collaborating physician about diagnosis and treatment are resolved. If the agreement does not state otherwise, the collaborating physician’s diagnosis or treatment will take precedence.
Peer review of patient records by the collaborating physician in a timely manner, but no less than once every three months. The number of charts that must be reviewed by the collaborating physician is not specified in New York Law. That decision is left to the NP and collaborating physician’s discretion, and it may vary depending on factors such as the NP’s experience, the collaborating physician’s knowledge of the NP’s abilities, the population to be served, and the practice setting.
Identification of written practice protocols to be used by the NP.
Provisions agreed upon by the NP and the collaborating physician.
A copy of the collaborative practice agreement must be kept at the NP’s practice location(s) and made available to the New York State Education Department for inspection (SED). A copy of the agreement is available at www.op.nysed.gov/prof/nurse/np-sample-collaborative-agreement.pdf. You can use that as an example.

Many NPs work for two or more health care providers or in a facility with patients being treated by multiple physicians. In such cases, the Education Law does not require the NP to enter into multiple collaborative agreements. As an example:

If an OB-GYN NP works three days a week at an obstetrician’s practice and two days a week at Planned Parenthood, the NP and the obstetrician could enter into a collaborative practice agreement. The collaborative practice agreement could designate a physician (other than the obstetrician) at Planned Parenthood to review the NP’s Planned Parenthood patients’ charts, or the obstetrician could review the NP’s Planned Parenthood charts. A second collaborative agreement is not required of the NP.
In the case of an NP working in a nursing home, the medical director may act as the collaborating physician. If an NP and an attending physician disagree, the medical director may mediate the dispute and make the final treatment decision. The NP is not required by law to have written collaboration agreements with all of the attending physicians.
Protocols for Written Practice
Nurse practitioners (NPs) must follow written protocols that reflect the specialty area(s) of practice in which they are certified. In addition, the protocols must reflect current, accepted medical and nursing practice. Additional protocols in subspecialty areas (for example, hematology, orthopedics, and dermatology) that are relevant to the NP’s practice may be used but are not required to be reflected in the collaborative practice agreement.

“Verification of Collaborative Agreement and Practice Protocol” Form 4NP
Within 90 days of beginning professional practice, a newly certified nurse practitioner (NP) must file Form 4NP-“Verification of Collaborative Agreement and Practice Protocol” with the New York State Education Department (SED). SED does not require the NP to file any additional Form 4NP. A signed Form 4NP does not constitute a collaborative practice agreement.

It should be noted that the Education Law does not require physicians to supervise or co-sign the NP’s orders or medical records. The collaborating physician is required to review the NP’s patient records at least every three months.

Relationships of Collaboration
Certain experienced nurse practitioners (NPs) are permitted to practice more autonomously under New York State Education Law. Each NP with more than 3,600 hours of qualifying NP practice experience may choose from the following options:

practice in accordance with a written practice agreement with a collaborating physician, as described above in Section II “Practicing in Accordance with a Written Practice Agreement with a Collaborating Physician”; or practice and have collaborative relationships with a qualified physician or a New York State Health Department licensed health care facility (i.e., hospital, nursing home, ambulatory surgery center, or diagnostic and treatment center), as described in more detail in Section II “Practicing in Accordance with a Written Practice Agreement with
The New York State Education Law defines “collaborative relationships” as when an NP communicates with a physician qualified to collaborate in the specialty involved by phone, in person, in writing, or electronically, or when a licensed health care facility communicates with a physician qualified to collaborate in the specialty involved who has privileges at such health care facility for the purpose of exchanging information in order to provide comprehensive care.

The NP may practice and form collaborative relationships if the following criteria are met:

The NP must have more than 3,600 hours of experience working as a licensed or certified NP under the laws of New York or another state, or working as an NP for the United States veteran’s administration, the United States armed forces, or the United States public health service.

The NP must have collaborative relationships with one or more physicians who are qualified to collaborate in the specialty in question, as well as with a New York State Health Department licensed health care facility (i.e., hospital, nursing home, ambulatory surgery center, or diagnostic and treatment center). The health care facility must provide services through physicians who have professional privileges at the health care facility and are qualified to collaborate in the specialty involved.

The NP must keep written or electronic documentation that supports his or her collaborative relationships. Documentation of this type may include, but is not limited to, the following:
Documentation of an agreement or arrangement with a hospital or physician practice under which an NP may transfer or refer patients for care; documentation of communication between the NP and a physician qualified to collaborate in the specialty involved relating to the care of the NP’s patients or referral of the NP’s patients; documentation of an employment relationship between an NP and a physician practice or a hospital, hospice program, licensed home care, or home health agency

The NP must make the “Collaborative Relationships Attestation Form” and supporting documentation for collaborative relationships available for inspection by SED.
According to New York State Education Law, NPs who practice and have legally authorized collaborative relationships are not required to:

sign a contract with a physician; practice in accordance with a written contract or written practice protocols; be supervised by a physician; or have a physician co-sign or review any of the NP’s orders, prescriptions, or other clinical records.
The New York State Education Law does not prohibit NPs who practice and have legally authorized collaborative relationships from engaging in the following activities:

practicing in accordance with clinical guidelines, policies, or protocols; entering into agreements or other clinical or business arrangements; communicating with health care service providers; or engaging in any quality assurance or other care-related activities
If a newly certified NP chooses to practice and maintain collaborative relationships in accordance with the new law, the NP is not required to file Form 4NP “Verification of Collaborative Agreement and Practice Protocol” with the New York State Education Department (SED).

IV. Financial Relationships Between a Nurse Practitioner and a Collaborating Physician
Financial relationships between health care practitioners are governed by a number of New York and federal laws. Some financial relationships between nurse practitioners (NPs) and collaborating physicians are prohibited by the Education Law or professional misconduct regulations (See, for example, Education Law 6513, 8 NYCRR 29.1), as well as other state or federal laws.

A collaborating physician and an NP are prohibited from engaging in “fee-splitting” or “kick-backs” under New York State Education Law and professional misconduct regulations. These legal prohibitions on “fee splitting” and “kick backs” are intended to ensure that medical and nursing decisions are made on the basis of sound clinical judgment, not economic or business considerations.

A “kick-back” occurs when a person gives or receives money or other consideration to or from a third party in exchange for referring patient services. For example, if a physician pays a nurse practitioner $100 for each patient referred to the physician for medical care, it is very likely that the physician is giving and the NP is receiving “kick-backs.”

If an NP shares his or her practice income or fees with a physician who is not the NP’s employer, this is known as “fee splitting.” In addition, “fee splitting” refers to arrangements or agreements in which the NP pays the collaborating physician a sum of money that is a percentage of, or otherwise dependent on, the NP’s income or receipts in exchange for the collaborating physician’s services. For example, if an NP pays the collaborating physician (who works at a separate medical practice) 20% of the NP’s professional income in exchange for the collaborating physician’s services, the NP and the physician are most likely engaging in illegal “fee splitting.”

The Education Laws prohibiting “fee-splitting” or “kick-backs” do not preclude a nurse practitioner from paying a collaborating physician the fair market value of the physician’s personal services (i.e., chart review and consultation) unless:

The payment includes remuneration for referring patients to the physician; or the payment is based on a percentage of or dependent on the NP’s professional fees or income.
When medically necessary, NPs may refer patients to their collaborating physicians, as long as the NP receives no compensation for the referral. A payment provision is not required in a collaboration agreement under New York law.

If you have any questions about collaborative relationships, collaborative practice agreements, or practice protocols, please contact the Nursing Board Office at nursebd@nysed.gov or 518-474-3817 ext. 120. It is not the Nursing Board Office’s responsibility to interpret laws governing financial relationships between NPs and collaborating physicians.

What type of professional relationship is currently required by New York State law for Nurse Practitioners in practice?

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