Your First Job:
Certification,
Licensure
Governing Boards
•
State Board of Medicine
•
•
Supervising Physician: M.D.
State Board of Osteopathic Medicine
•
Supervising Physician: D.O.
Utilization
• Hospital and long term care facility
– Review Bylaws
– Obtain facility credentials
•
•
•
•
•
Emergency Room (direct supervision required)
First Assist at surgery
Moonlighting
House Calls
Industrial sites
Satellite Location
State Board of Medicine
- Separate approval
- Area of medical need
- M.D. reviews all patient
records
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-
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• State Board of
Osteopathic Medicine
Separate approval
D.O. can only have one
satellite location
D.O. sees adult patients
every 5th visit, infant to 2
year olds every 3rd visit,
age 2-18 year olds every
other visit
PA in main office for one
year
Satellite Location – MD Board
• supervising physician must “Review directly with patient,
the progress of patient’s care as needed based upon
patient’s medical condition and prognosis or as
requested by patient.” In other words, physician is given
latitude to determine when patient needs to be seen
unless requested by patient.
• supervising physician must “visit the satellite
location at least once every 10 days and devote
enough time onsite to provide supervision and
personally review records of selected patients seen
by the physician assistant in this setting. Supervising
physicians shall notate those records as “reviewed.”
Primary Supervisor
• Obtain approval from respective board
• Assumes full medical and legal responsibility for
PA
– Oversight and personal direction of, and responsibility for, the
medical services rendered by a physician assistant
– An appropriate degree of supervision includes:
• (A) Active and continuing overview of the physician
assistant's activities to determine that the physician's
directions are being implemented
• B) Immediate availability of the supervising physician to the
physician assistant for necessary consultations.
• (C) Personal and regular review within 10 days by the
supervising physician of the patient records upon which
entries are made by the physician assistant.
Primary Supervisor (con’t)
• Reviews all PA records
– Require that the supervising physician shall
countersign the patient record completed by the
physician assistant within a reasonable amount of
time. This time period may not exceed 10 days.
Alternate Supervisor
• Assume full medical and legal
responsibility for PA when primary
supervisor is away
• MD/DO mixed group
- If DO supervising, can not independently
prescribe
Role of the PA
• Perform duties and responsibilities, including ordering, prescribing,
dispensing, and administration of drugs and medical devices, as
well as ordering, prescribing, and executing of diagnostic and
therapeutic medical regimens, as directed by supervising physician.
• Provide any medical service as directed by supervising physician
when service is within physician assistant’s skills, training and
experience, forms a component of physician’s scope of practice, is
included in written agreement and is provided with amount of
supervision in keeping with accepted standards of medical practice.
• Pronounce death, but not cause of death, and may authenticate,
with physician assistant’s signature, any form related to pronouncing
death. If attending physician is not available, physician assistant
shall notify county coroner. Authority to release body of deceased to
funeral director shall be that of coroner
Role of the PA
• Authenticate, with physician assistant’s
signature, any form that may otherwise be
authenticated by a physician’s signature as
permitted by supervising physician.
• A physician assistant may execute written or oral
order for medical regimen or may relay written or
oral order for medical regimen to be executed by
a health care practitioner subject to the
requirements of this section.
Role of the PA
• As provided for in written agreement, the physician assistant shall
report orally or in writing to a supervising physician, within 36 hours,
those medical regimens executed or relayed by the physician
assistant while the supervising physician was not physically present,
and basis for each decision.
• The physician assistant shall record, date, and authenticate the
medical regimen on the patient’s chart at time it is executed or
relayed. When working in a medical facility, a physician assistant
may comply with the recordation requirement by directing recipient
of order to record data, date and authenticate that the recipient
received the order, if this practice is consistent with the
Prescription Pad
• Name of PA and supervising and alternate
physician names
• License number of PA and supervising
and alternate physician names
• Office address and phone number
• Blank for DEA number
– When appropriate, the physician assistant’s DEA
registration number must appear on the prescription
Prescription Documentation
• Record drug name, amount, dose,
frequency, refills and date in chart
Prescribing Authority
• The supervising physician may delegate authority to
prescribe to the PA.
• A physician assistant authorized to prescribe or
dispense, or both, controlled substances must register
with the Drug Enforcement Administration.
• Controlled Medications
– Schedule 1 – NO!!!!
– Schedule 2 – May initiate therapy for 72 hours or may
refill as prescription initiated by the supervising
physician for up to 30 days for ongoing therapy
– Schedule 3-5 – May prescribe per DEA guidelines
Prescribing Authority
• A physician assistant may only prescribe or dispense a drug for a
patient who is under the care of the physician responsible for the
supervision of the physician assistant and only in accordance with
the supervising physician's instructions and written agreement.
• A physician assistant may request, receive and sign for professional
samples and may distribute professional samples to patients.
• The supervising physician is prohibited from pre-signing prescription
blanks.
• The supervising physician shall immediately advise the patient,
notify the physician assistant and, in the case of a written
prescription, advise the pharmacy, if the physician assistant is
prescribing or dispensing a drug inappropriately.
DEA application
• Applications distributed from Philadelphia DEA
office only
• $551.00 for three years
• Request:
– DEA application
– Mid level practitioner addendum form
– Mid level practitioner prescribing manual
• If change jobs, notify of change of address
• Use for Schedule II-V medications only
– Sched. II 72 hours for initial or 30 days if renewing a
Rx. Originated by a physician.
Written Agreement
• Outlines supervision relationship
• Outlines PA job description
• Outlines medication that PA will be
prescribing
• Designates location of PA utilization
Required Identification
• Public notice posted
• Display state approved credentials for PA
and supervising physician
• Name tag with 16 point type with
“Physician Assistant” spelled out
Emergency Medical Services
• A physician assistant may only provide medical service
in an emergency medical care setting if the physician
assistant has training in emergency medicine, functions
within the purview of his written agreement and is under
the supervision of the supervising physician.
• A physician assistant licensed in this State or licensed or authorized
to practice in any other state of the United States who is responding
to a need for medical care created by a declared state of emergency
or a state or local disaster (not to be defined as an emergency
situation which occurs in the place of one’s employment) may render
care consistent with relevant standards of care.
New Graduate
•
•
•
•
• State Board of
Medicine
Temporary permit
Direct supervision
No prescribing
Once nationally
certified, must have
NCCPA notify board
to get changed to
permanent statusmust ask NCCPA to
notify the SBM
directly
• State Board of
Osteopathic Medicine
• No provision for a
new graduate
New Graduate Registration
• Request copies of needed forms and copy of Medical or Osteopathic
Practice Act from board
• Only use original forms
• Complete fully and legibly
• Use similar language as the regulations use for written agreement
and check all drug categories (for MD)
• PA program will need to complete a page of application verifying
graduation
• Make copies of forms
• Send in same envelope by certified mail
• Send in correct amount of payment
• Wait for official certificate from the board and the official letter of
approval for supervisor before beginning to practice
• Typical wait is 4-8 weeks
Paperwork approval
• State Board of Medicine meets the third
Tuesday of month
• State Board of Osteopathic Medicine
meets second Wednesday of month
• Need paperwork there in time to be put on
agenda
• If change jobs, must have complete
paperwork approved before start of work
Contact information
NCCPA (770)-734-4500
http://www.nccpa.net
State Board of Medicine (717)-787-2381
http://www.dos.state.pa.us/
State Board of Osteopathic Medicine
(717)-783-4858
Drug Enforcement Administration
(215)-597-9536
American Academy of Physician Assistants
(703)-836-2272
http://www.aapa.org
Reimbursement
Scope of Practice
Reimbursement Issues
• Need to learn about insurance company reimbursement
for medical and surgical physician services provided by a
PA
• Identify major carriers for your practice
• Obtain Medicare number
• Be aware of restrictive supervision requirements
• Review HMO practice contracts
• Obtain AAPA book entitled “Third Party Reimbursement”
• Visit AAPA website for reimbursement information
• Review documents on AAPA fast fax
• Non Physician Practitioner News newsletter
• Part B News newsletter
Medicare Reimbursement
• Office setting
– MD on site
– MD off site
•
•
•
•
House call
Skilled Nursing Facility
Hospital
Federal Rural Health Site
• HMO
100%
85%
85%
85%
85%
is cost based
reimbursement
Capitated
Medicare Incident-to
• To obtain 100% reimbursement three
criteria must be meet:
– Physician must be on site
– Physician must see all new patients
– Physician must see established patient if
there is any change in condition
Other insurance carriers
• Medicaid Varies by site but majority is 100% (physician off
site)
• TRICARE 85% (surgery 65%)
• Private insurance varies (need physician on site)
– Blue Cross/ Blue Shield permits physician off site if in medically
underserved areas otherwise physician needs to be on site
– PAs services as a surgical assistant is part of surgeon’s surgical fee
• Workman’s comp Reimbursed in PA
– (% depends on service)
• FEHB Program majority cover, but varies
– Foreign Service no
– Mail Handlers
no
– Rural Carriers
no
Billing Rules
• Not documented = not done
• Not done = not billable
• Billing must reflect level and intensity of
service documented
Salary and
Demographics
Income Variables
• Specialty
• City size
• Years of experience
Salary and Benefits
• Income can be by salary, fee for service or
hourly
• Benefits vary
• Malpractice (verify in place before seeing
patients and see policy in writing)
- Supervisor’s policy rider
- Umbrella policy
- Independent policy
TABLE 18 Benefits paid by employer
Professional Liability Insurance
99.1%
Individual Health Insurance
94.3%
Family Health Insurance
88.7%
Dental Insurance
75.9%
Disability Insurance
72.2%
Term Life Insurance
66.8%
Pension Retirement
83.5%
DEA Registration
78.7%
NCCPA fees
68.5%
AAPA dues
72.3%
State chapter dues
62.7%
Credentialing fees
83.4%
2007 AAPA Salary Survey
Specialty
Pennsylvania
Family Medicine
GIM
Emergency Med
Gen. Peds.
$67,274
$70,916
$83,098
$62,343
Gen. Surgery
Int. Med. Sub.
Ped. Sub.
$71,907
$72,437
$70,693
Surg. Sun
OB/GYN
Occ. Med.
$81,003
$65,546
$74,113
Salary by years as a PA
Less than one year
$63,753
1-3 Years
$69,501
4-6
$79,013
7-9
$81,619
10-12
$85,869
13-15
$77,952
16-18
$78,521
More than 18 years
$84,256
Advertise your addition to
practice
• In town newspaper
• In hospital newsletter
• Notify hospital and nursing home
department heads and nursing units
• Educational brochures in waiting room
• Letters of introduction to office patients
Get the professional edge
Position yourself as source of
knowledge
Provide written information to add clout
Get the edge in hiring process
Malpractice
Avoiding Malpractice
• Diagnostic errors – majority of lawsuits
against PCP
• “Red flags” complaints with a statistically
high probability for lawsuits in primary care
• Rule out worst things first
• Revisit unsolved problems
• Have patient’s chart in front of you when
you give phone advise
Medical Charting
• Documentation – if it is not written down,
you didn’t do it
• Documentation of telephone calls in the
chart
• Dispense instruction sheets
• Document patients refusal of treatment
• Document risks of failure to comply
Altering the Medical Record
• New entry with date and reason for
addition
• Never alter a record by writing in the
margin, writing over an entry or changing a
date
• Never write or stamp “dictated but not
read”
Medication Errors
• 2nd most common / 2nd most expensive
• Over half of all preventable drug events
occur in the ordering process
• Causes
– Incorrect dose
– Inappropriate drug for the medical condition
– Failure to monitor for side effects
Ways to Lower Risk
• Write legibly
• Document on a medication flow sheet in
the front of the chart (also keep track of
refills)
• Chart herbal medication use
• Reduce errors
– Use leading zeros
– Avoid trailing zeros
– Avoid abbreviations
0.5 mg
5 mg
Systems for Tracking
Follow-up
• Keep logs
– Diagnostic tests (review daily)
– Referrals (review monthly)
• Problem lists
• Develop a back up system to review labs
when a provider is not in the office
• Checklist charting of visits / preprinted
forms
• Checklist documentation of telephone calls
NCCPA Certification
NCCPA: Who are they?
• Primary resource in the assessment and
credentialing of Physician Assistants
• Formed by 14 organizations in 1975
• Responsible for administration of the
national certification examination
NCCPA: Initial
Certification
PANCE:
Physician Assistant National Certifying Examination
• What is PANCE?
– Initial certifying examination for Physician Assistants
• General Eligibility:
– Graduate of, or nearing graduation from an accredited
PA program
• Test Composition
– Physician Assistant Tasks and Evaluative Objectives
– Sample Disease/Disorders by Organ System
PANCE:
Physician Assistant Tasks and Evaluative Objectives
18
– Seven Categories
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•
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•
A:
B:
C:
D:
E:
F:
G:
H&P
Lab & Diagnostic tests
Diagnosis Formulation
Clinical Intervention
Clinical Therapeutics
Health Maintenance
Application of
scientific concepts
16
14
12
10
8
6
4
2
0
A
B
C
D
E
F
G
PANCE:
–
–
–
–
–
–
–
–
–
–
–
–
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Sample Disease/Disorders by Organ System
A. Cardiovascular
B. Pulmonary
C. GI/Nutrition
D. MS
E. EENT
F. Reproductive
G. Endocrine
H. Neuro
I. Psych
J. GU
K. Derm
L. Heme
M. ID
16
14
12
10
8
6
4
2
0
A B C D E F G H I J K L M
PANCE: Dates and Deadlines
Cost $425
• Testing Before March
2008
– Earliest date is 7 days after
graduation
– Can only take once every
90 days or 3 times in a
calendar year.
– If there is a chance you
won’t complete program on
time, wait to register until
confident of
graduation/completion date
• Testing After March 2008
– Register not sooner that 90
days prior to completion
date
– You have 180 day window
to take the exam
– Can only take once every
90 days or 3 times in a
calendar year
– If there is a chance you
won’t complete program on
time, wait to register until
confident of
graduation/completion date
PANCE:
Common Questions
– What must I score to become certified?
• 55-65% depending on test version
– What happens if I don’t pass my exam?
• May take numerous times if graduated before 2003
• 2003 and beyond – you have 6 attempts in six years to pass. Can
only take one in a 90 day period and the maximum attempts is 3
times in one year.
– When will I receive my score?
• Mailed within 2 weeks after your exam date
– How do I set up my exam time?
• Scheduling permit card will be sent to you about a month after
making application to take exam
Maintaining Certification
• Three Steps
– CME logging – all logging must be done with
NCCPA. $95 logging fee ($15 discount if done
on-line)
– Re-registration
– Recertification
CME Logging
• Frequency:
• Every two years must complete 100 hours
• CME requirements
•
•
•
•
•
Category I (50 pre-approved hours)
Category II
Clinical (medical or patient care)
Professional (indirectly related to patient care)
100 hours total
Re-registration
• Frequency
– 2nd and 4th year of certificate maintenance
process. Complete form and submit payment
• Deadlines
– Certificates expire every June
– Recommend complete prior to May to assure
continual certification
Recertification
• Two Options:
– PANRE: Physician Assistant National
Recertifying Examination
– Pathway II : Exam and Elective Component
Recertification:
continued
PANRE -$300
PATHWAY II -$475
Exam Location
Pearson VUE Testing Center
Take-home Exam
Format
360 MCQ (Computer)
No Reference Material
300 MCQ
Open Book Format
Passing
Standard
51-64 %
70-80%
Time Allotted
5 Hours
Up to 6 weeks
NOTE:
Individuals may take PANRE
one time in any single 90-day
period with a maximum of two
(2) attempts per year.
Pathway II ends in 2010
Pathway II
• Must earn total of 100 points within at least
two of the nine categories
• Points earned through entire 6 year
certification cycle
• Currently, Pathway II is being discontinued
in 2010
Pathway II:
Elective Component
• Nine Elective Component Categories
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–
–
–
–
–
Clinical Category I (Pre-Approved) CME (1 pt./hr.)
Clinical Skills Training
Medical Teaching (1-2 pts./hr.)
Publications
Postgraduate Courses (50 pts. max.)
Professionally Relevant Postgraduate Degree
• (50 pts. max.)
– Surgery Examination (25 pts.)
– Specialty Review (25 pts. max.)
– Other
Failure to Pass
• If your certification expires in 2002 or
beyond, you must pass by the end of the
6th year.
• You can take the test in years 5 and 6.
• You have 4 attempts to test and pass.
Questions??