Practice Management Curriculum Effectively Integrating Non ...


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  • We use the term NPP throughout these slides since it is Medicare’s term – but physician extenders and mid-level providers are also commonly used and can be used interchangeably.
    We will focus our discussion on nurse practitioners and physician assistants. Clinical nurse specialists are commonly used in the hospital setting, less frequently used in office practice. Licensure and scope of practice are generally more limited for clinical nurse specialists, and credentialing and reimbursement is difficult in many (most) states.
  • Cost effective way for patients to receive quality care
    Allow more flexibility in scheduling patient visits, more consistent schedule than MDs
  • Survey data includes 35 practices.
    This is the second year that we have noted that physicians in practices that have non-physician practitioners are able to see significantly more new patients that physicians without NPPs.
  • Coverage for MD vacations – improved continuity of care
    Review/ discuss John’s pro forma – should we include as a slide?? Or a handout??
  • ?? ONS
  • Medical model – training is more similar to physician training; training is clearly as an assistant to the MD
    Nursing model – many NPs having nursing backgrounds; all are trained with emphasis on patient education
  • More payer info later in the talk
  • Patient education – some practices have shifted primary patient education duties (chemotherapy teaching, research protocol teaching) to an NP rather than nurse because NPs can appropriately bill a higher level of service
  • Slide 36:
    Services can be considered incident to when physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of course of treatment
  • AAPA – American Academy of Physician Assistants
  • Drugs are paid at ASP + 6 whether the service is billed under the MD # or the NPP #
  • Remember that incident to is a Medicare term and they may not know what it means
  • Practice Management Curriculum Effectively Integrating Non ...

    1. 1. Practice Management Curriculum Effectively Integrating Non-physician Practitioners in Oncology Practice
    2. 2. After this session, you will be able to: • Describe the types of non-physician practitioners in oncology practices; • Identify important elements of state scope of practice and the specifics in your state; • Discuss a variety of practice models for non- physician practitioners in oncology practices; • Know the rules for billing for non-physician practitioner services; and • Understand the value of non-physician practitioners and how to successfully integrate them into your practice.
    3. 3. Who are Non-physician Practitioners? • Non-physician practitioner (NPP) is the Medicare term • Also known as physician extenders, mid-level providers • In oncology, typically refers to nurse practitioner or physician assistant; sometimes clinical nurse specialist
    4. 4. Benefits of Using NPPs • Increase new patient capacity and overall patient volume at less expense than adding a new physician – NPP can see follow up patients creating time for physician to see consultations and new patients
    5. 5. Impact of NPPs on Physician Productivity New patients / FTE medical oncologist Barr, T, Towle, E, Jordan, W: The 2007 National Practice Benchmark: Results of a National Survey of Oncology Practices. Journal of Oncology Practice 4:178-183, 2008
    6. 6. More Benefits • Generate practice revenue when physicians are out of the practice – Chemotherapy and other services can be rendered incident to an NPP – Do careful financial analysis when billing services using the NPP provider # • Payment is at 85% of the physician fee schedule rate • Serve as clinical resource for nurses, other staff and patients when physician not available
    7. 7. Enhance Patient Satisfaction • Reduce patient wait times – NPPs frequently add flexibility to the appointment schedule – Patients can get appointments sooner and help decrease wait time in lobby • Increase time spent with patients • See urgent problems in a timely manner
    8. 8. Patient Satisfaction • More than 60 percent of group practices (all specialties) now employ NPs and PAs, and most enjoy gains in patient satisfaction, productivity, and income as a result. • Studies show that more than 90 percent of patients who see NPs or PAs are satisfied with their care, and observe that these providers have good listening and counseling skills. Duke University, Summer 2002
    9. 9. Physician Satisfaction • 2006 Survey of Clinical Oncologists, Forecasting the Supply of and Demand for Oncologists • 56% of respondents work with NPs and/or PAs – 30% work with NPs/PAs in “traditional scope of practice roles”: patient education and counseling, pain and symptom management, manage patients during visits – 26% work with NPs/Pas for “more advanced procedures”: assisting with NP consults, ordering routine chemotherapy, performing invasive procedures
    10. 10. Physician agreement with statements regarding use of NPs/PAs Traditional Role Advanced Role Increases the efficiency of my practice 70% 92% Allows me to spend more time on complex cases 73% 87% Contributes to my professional satisfaction 66% 85% Improves overall patient care 69% 88%
    11. 11. Oncology Workforce • ASCO workforce study predicts a “state of acute shortage” of oncologists by 2020 – Number of oncologists is projected to increase by 20% BUT need for oncology services will increase by 48% resulting in overall shortage – Increased use of NPPs is one strategy Erikson C, Salsberg E, Forte G, et al: Future supply and demand for oncologists. Journal of Oncology Practice 3:79-86, 2007
    12. 12. NP and PA Growth • Dramatic growth in number of PAs and NPs between 1999 and 2005 – 55% growth in number of PAs – 61% growth in number of NPs • American Academy of Physician Assistants (AAPA) projects continued PA workforce growth of 49% between 2005 and 2014 • Continued growth of NP workforce less certain
    13. 13. Nurse Practitioner • Registered Nurse with advanced education and clinical training in a health care specialty area – Medicare requires Master’s degree in nursing • Practice under the rules and regulations of the Nurse Practice Act of the state in which they work • Practice independently and/or in collaboration with other health care professionals • Prescriptive authority is specific to each state
    14. 14. Nurse Practitioner • Services may include – Diagnosing, treating, evaluating and managing acute and chronic illness and disease – Ordering, conducting, supervising and interpreting diagnostic tests – Prescription of pharmacologic agents and non- pharmacologic therapies – Counseling and educating patients on health behaviors, self-care skills and treatment options
    15. 15. Nurse Practitioner • Credentialed through a variety of organizations including American Nurses Credential Center, American Academy of Nurse Practitioners, Oncology Nursing Certification Corporation – Re-certification required every 5 – 6 yrs – Continuing education requirements • Many practices provide financial support for certification and continuing education
    16. 16. Physician Assistant • Health care professional licensed to practice medicine with physician supervision – Increasing number of states are requiring Master’s Degree; not required by Medicare • Specific duties vary with training, experience and state law • Scope of practice corresponds to the supervising physician’s practice – Licensure and regulation generally governed by Board of Medicine
    17. 17. Physician Assistant • Services may include – Diagnosing and treating illnesses – Conducting physical examinations – Ordering and interpreting tests – Counseling on preventative health care – Assisting in surgery – Writing prescriptions (in 49 states)
    18. 18. Physician Assistant • Certification is through the National Commission on Certification of Physician Assistants (NCCPA) – Designated PA-C (Physician assistant-certified) – Initial certification, renewal every 6 years – Continuing education requirement
    19. 19. NP or PA? • Education and training – PA: Bachelor’s Degree or Master’s Degree; educated in the medical model designed to complement physician training – NP: Master’s Degree required in most states; nursing model • Supervision or collaboration – PA: All states require some level of supervision; most (not all) allow electronic communication – NP: Some states allow independent practice; 28 states require collaborative practice agreement with a physician
    20. 20. NP or PA? • State Scope of Practice – PA: generally licensed/regulated by Board of Medicine – NP: generally licensed/regulated by Board of Nursing – State scope of practice varies widely from state to state for both NPs and PAs • Prescriptive Authority – Like scope of practice, wide variation between NPs and PAs, and from state to state
    21. 21. NP or PA? • Payer issues – Most - but not all - payers recognize both NPs and PAs; you must know your payer market • Practice model – Physician experience, preference – Acceptance by staff • Community norm – Acceptance by patients, referring physicians – Job description, duties, goals
    22. 22. NP or PA? • Background – Many NPs interested in oncology have an oncology nursing background – May have been an OCN-certified RN, then received advanced training as a nurse practitioner – Look for the AOCN certification
    23. 23. Your State • State specific information on scope of practice, licensure and prescriptive authority is included in your meeting materials
    24. 24. How common are NPPs? • 2006 Survey of Clinical Oncologists (from Forecasting the Supply of and Demand for Oncologists, 2007) – 56% of respondents reported that they work with NPPs • Onmark Office-based Oncology Business Benchmarking Survey, 2007 report – 49% of respondents work with NPPs – Average of 0.5 NPP / FTE physician • Oncology Metrics’ National Practice Benchmark, 2008 report – 62% of respondents work with NPPs – Average of .46 NPP / FTE physician
    25. 25. Practice Models • Practice models vary – Work with all physicians • See all patients as determined by practice – Work one-on-one with a single physician – Team with small group of physicians • In many practices, NPPs see patients independently – Physicians are available but do not participate in every visit – NPPs have a separate patient schedule
    26. 26. Practice Models • Focus on patient education – In some practices, NPPs do a pre-chemotherapy evaluation that replaces the nursing chemo class or teaching visit – A billable event when performed by NPP and appropriately documented – Introduces the NPP early in the care cycle as the resource for chemotherapy side effects, problems
    27. 27. Practice Models • Disease specific models – Breast center – Bone marrow transplant • Clinical Research – Function as sub-investigator to the PI • Sign off on data discrepancies, adverse events; flag lab abnormalities; sign chemo orders; perform physical exams – all under the direction of the PI • Improved efficiency for PI, less costly for the practice
    28. 28. Practice Models • Inpatient hospital services – Daily hospital rounds, prep work for consultations • A tool to improve physician efficiency in the hospital – Hospital privileges vary dramatically • Satellite office coverage – Financial modeling is important • Infusion suite coverage – For large infusion suites, NPP is immediately available as resource to nurses, patients
    29. 29. Practice Models • Palliative care focus • Resource for psychological and social issues • Pain management • Survivorship clinics
    30. 30. Procedures • Many NPPs perform procedures – Bone marrow biopsy and aspirate, lumbar puncture, intrathecal chemotherapy • Must follow state scope of practice • Training and supervision are important
    31. 31. Consultations • According to Medicare guidelines, NPPs can perform consultations if allowed by state scope of practice • Be cautious – Referring physicians may object – If a physician never provides a direct professional service (E/M) to the patient, NPP services cannot be billed as incident to
    32. 32. Call Coverage: PAs • 2007 survey by American Academy of Physician Assistants (AAPA) – 23% of PAs take some call (down from 32% in 2005 survey) – 6.4% indicate they receive some compensation for on- call services (down from 16% in 2005 survey)
    33. 33. Call Coverage: PAs 2007 AAPA Physician Assistant Census Report for Oncology PAs y07C.pdf Medical Oncology Count Percent Respondents 366 100.0% Do not take call 269 73.5% Take some call 83 22.7% Always on call 13 3.6%
    34. 34. Call Coverage: NPs • 2007 National Salary Survey of Nurse Practitioners by Advance for Nurse Practitioners – 25% of respondents report call duty as part of their job • 38% of that group report specific additional compensation • NPPs (both PAs and NPs) should always have physician back-up available when taking call
    35. 35. Hiring a Non-physician Practitioner • Understand state requirements and regulations • Develop a job description – Involve physicians and nurses in the process • Advertise both locally and nationally – Use national association websites and journals – Contact local NP/PA training programs; consider a student internship
    36. 36. Hiring a Non-physician Practitioner • Offer a competitive salary and benefits • Take your time – Expect it to take as long as a physician search • Look at your own practice – is there an OCN nurse that might go back to school to become a nurse practitioner? • Plan your training process – it’s hard to find an NPP with oncology training
    37. 37. Compensation • Salary is always local; check local resources first – State or regional Medical Group Management Association (MGMA) chapters – Local PA or NP society, ONS chapter – Hospitals or other practices or in your area
    38. 38. Compensation • Other resources – MGMA Compensation and Production Survey • – 2007 American Academy of Physician Assistants, Physician Assistant Census Report for Oncology • 07C.pdf – Advance for Nurse Practitioners 2007 Salary Survey Results • Salary-Survey-Results-A-Decade-of-Growth-3.aspx
    39. 39. Integrating NPPs into Practice: Physician Role • When developing the job description – Discuss how each physician feels they will work with the NPP and try to come to consensus – Determine the practice model before NPP starts • Will the NPP see patients for all physicians or only specific physicians? • Will they be assigned to a specific function or disease – breast center, clinical research?
    40. 40. Physician Role • Be prepared to invest time in education – Plan and schedule specific training with physicians, other NPPs, possibly nurses • Job shadows • Round with physicians • Didactic sessions – Develop a curriculum or training plan – Consider local chemotherapy course as introduction if needed – Mentor – Evaluate and provide feedback regularly
    41. 41. Integrating NPPs into Practice: Nurses • Discuss the plan to add an NPP with nurses early in process – More flexibility in patient scheduling, continuity of care, reimbursement issues, etc. • Ask for nursing input into development of job description • Involve nurses in orientation and training process, especially for NPPs with limited oncology experience
    42. 42. Integrating NPPs into Practice: Patients • Physician introduction whenever possible • Always inform patients when they will see the NPP – Describe NPPs as part of the “patient care team” with the physician and nurse • Include NPP information in written materials about practice and on practice website • NPP credentials should be visible
    43. 43. Integrating NPPs into Practice: Staff • Physicians and administration will set the tone for the staff – The NPP is a provider • A confident and respectful staff attitude is important in instilling confidence for patients
    44. 44. Integrating NPPs into Practice: Referring Physicians • Include NPP names on signage, marquees, letterhead, practice website • Personally introduce NPPs to key referring physicians; invite NPP participation in tumor board meetings • Physician should discuss NPP involvement in cases with referring physicians
    45. 45. Billing Issues: Medicare • Medicare will pay for services furnished by physician assistants, nurse practitioners and clinical nurse specialists in the same manner as if the services were furnished by physicians • Services must be within scope of practice of the NPP under state law • NPPs must accept assignment on all claims • Services may be billed incident to a physician or using the NPP provider number
    46. 46. Incident to is a Medicare Term • In a non-institutional setting (other than a hospital or skilled nursing facility), Medicare pays for services furnished incident to a physician’s or other practitioner’s services • Services and supplies must – Be an integral, although incidental, part of the physician’s professional service; – Be commonly furnished in physician’s offices or clinics; – Be furnished under the physician’s direct supervision; – Represent an expense incurred by the physician
    47. 47. Direct Supervision • Physician must be present in the office suite – but incident to does not require direct involvement of physician in every service • Services can be considered incident to when physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of course of treatment • Supervising physician can be another physician from the group practice
    48. 48. So what does this mean? • NPP services can be rendered incident to a physician service – NPP can provide complete service; service is billed and paid as though it was provided by the physician – Physician must demonstrate active involvement in the patients case but does not have to see the patient at every NPP visit
    49. 49. It Also Means... • Services can be rendered incident to an NPP if physician is not available or present in suite – If allowed within state scope of practice • Chemotherapy (and other services) can be provided incident to the NPP – NPP must be present in the office suite and immediately available to provide assistance if required
    50. 50. If the services is not incident to • For Medicare patients, bill under NPP’s ID number – Physician fee schedule services (E/M, drug administration) are paid at 85% of the physician fee schedule amount – No change in drug payment – Careful financial analysis is important
    51. 51. Billing Issues: Other Payers • May or may not recognize non-physician practitioners – Most payers do • May recognize NPs and not PAs or vice versa • Some require individual provider numbers; others require that you bill under the physician name/number
    52. 52. Billing Issues: Other Payers • Credential as required by each individual payer • Identify billing issues and comply with individual payer requirements • Educate payers as needed – Emphasize importance to patient care process – Use other payer policies as examples if needed
    53. 53. Billing Issues: Other Payers • Research policies for each of your major payers – Some may not have written policies – At minimum, get policy verbally and confirm in writing, then follow their requirements • Suggest payers follow Medicare’s lead – Allow coverage for services as though provided by physician – Pay “incident to” or using NPP provider number
    54. 54. One More Consideration: Productivity Tracking • Most practices track physician productivity for compensation and/or work load assignments • Important to discuss and decide how to track NPP services – Are NPP services tracked collectively or by individual provider? – Are incident to services attributed to the patient’s attending physician? Or the supervising physician in clinic? – What about services billed under the NPP’s provider number?
    55. 55. The Benefits • Easier to hire and less expensive than adding a medical oncologist • Increase physician and practice productivity • High patient and physician satisfaction • Valuable members of the oncology practice care team
    56. 56. ASCO Resources
    57. 57. ASCO in ACTION • Bi-weekly e-newsletter via ASCO Express • Updates on legislative and regulatory issues • Updates on CMS initiatives • Links to important resources, tools, and legislation • Available online
    58. 58. Alerts & Breaking News • Alerts and breaking news on issues affecting oncology • Sent to ASCO members • Available on ASCO website
    59. 59. • For Practice Managers and Executives • Highlights key issues • Resources for you, your practice, your staff, and your patients • To subscribe, email
    60. 60. Journal of Oncology Practice • Regular features include – Original Research – Practice of Research – Business of the Business – Ethics Vignettes – Practical Tips – Strategies for Career Success • Manuscripts and letters to the editor may be sent to
    61. 61. Practical Tips for the Oncology Practice • Detailed information about coding, billing, Medicare coverage guidelines • Includes excerpts from Medicare coverage manuals • Order at
    62. 62. EElectroniclectronic HHealthealth RRecordsecords • ASCO Electronic Health Record Initiatives at: – • Social networking site – • EHR Lab at 2011 ASCO Annual Meeting
    63. 63. Why are we talking about Health Information Technology? • Patients • Payers • Practice
    64. 64. Clinical Tools & Guidelines • Executive summaries • Flow sheets • Patient guides
    65. 65. Coding & Reimbursement Assistance • • ASCO member benefit, provided free of charge to ASCO members and their staff • Available to non-members for a nominal fee per inquiry
    66. 66. ASCO University • Three online modules – Oncology Billing and Coding Primer – Coding & Billing Case Applications – Medicare Case Applications • Excellent resource for your staff • Includes Certificate of Completion
    67. 67. Practice Management Curriculum – Communicating Cancer Care Costs – Adapting to Medicare Changes – Generating Practice Efficiencies – Health Information Technology in Practice – Effectively Integrating Non-physician Practitioners in Oncology Practice – Practice Check-up: Assessing the Financial Health of Your Practice
    68. 68. Contact Us • ASCO’s Cancer Policy & Clinical Affairs Department – 571-483-1670 – or –
    69. 69. Medicare • • Information for Medicare fee-for-service NPPs who provide services to Medicare beneficiaries – – Includes links to manuals, CMS transmittals, MLN articles, enrollment procedures
    70. 70. Other Organizations • American Academy of Physician Assistants – • Oncology Nursing Society – actice.shtml • American Academy of Nurse Practitioners –