Your First Job:Certification, Licensure

Patrick J. Ivory, MPAS, M.Ed., PA-C

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

• 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 status- must 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)-734-4500http://www.nccpa.net

State Board of Medicine (717)-787-2381http://www.dos.state.pa.us/

State Board of Osteopathic Medicine (717)-783-4858

Drug Enforcement Administration (215)-597-9536American Academy of Physician Assistants

(703)-836-2272http://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 100%– MD off site 85%

• House call 85%• Skilled Nursing Facility 85%• Hospital 85%• Federal Rural Health Site is cost based

reimbursement• HMO 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 $67,274

GIM $70,916

Emergency Med $83,098

Gen. Peds. $62,343

Gen. Surgery $71,907

Int. Med. Sub. $72,437

Ped. Sub. $70,693

Surg. Sun $81,003

OB/GYN $65,546

Occ. Med. $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 0.5 mg– Avoid trailing zeros 5 mg– Avoid abbreviations

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

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A B C D E F G

– Seven Categories • A: H&P

• B: Lab & Diagnostic tests

• C: Diagnosis Formulation

• D: Clinical Intervention

• E: Clinical Therapeutics

• F: Health Maintenance

• G: Application of scientific concepts

PANCE: 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. ID0

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A B C D E F G H I J K L M

PANCE: Dates and DeadlinesCost $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– 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??