Medical Assistants: Scope ofPractice, Education, and Credentialing National Council of State Boards of Nursing June 21, 2012 Donald A. Balasa, JD, MBA Executive Director, Legal Counsel American Association of Medical Assistants
• Medical assistants are allied health professionals who work primarily in outpatient/ambulatory health care delivery settings, most often under direct physician supervision, and who are able to be delegated both back-office clinical duties as well as front-office administrative duties.• Medical assistants are different from: (1) nursing assistants; and (2) medication aides/assistants.
• Nursing assistants work primarily in inpatient settings, most often under registered nurse (RN) supervision, and are delegated bedside, clinical duties.• Medication aides/assistants work primarily in inpatient settings, and are able to pass medications to patients, usually under RN supervision.• In some states, medication aides/assistants must first be certified nursing assistants (CNAs). In other states, individuals can be medication aides/assistants without being CNAs.
• Because medical assistants are delegated duties by physicians, in most jurisdictions medical assistants derive their legal authority to practice from state medical practice acts and regulations of the state boards of medical examiners.• In most jurisdictions, medical assistants work under direct physician supervision. “Direct supervision” is usually defined as the delegating/supervising/overseeing physician(s) being on the premises and reasonably available when the medical assistants are undertaking clinical duties.• From a precise legal standpoint, medical assistants are not delegated nursing duties. They are delegated clinical and administrative duties by physicians.
• Under the laws of most states, physicians are permitted (explicitly or implicitly) to ask advanced practice registered nurses (most frequently nurse practitioners), physician assistants, and registered nurses to supervise medical assistants in the performance of duties delegated to the medical assistants by the physician(s).• According to Working with Others: A Position Paper, National Council of State Boards of Nursing: – Accepting an assignment to supervise—There are situations when a nurse may be assigned to supervise a staff member who has been delegated tasks by another licensed provider (e.g., in a physician’s office). There are other situations where the authority to provide tasks or procedures…has been granted by a statute or rule/regulation separate from the Nurse Practice Act or rules/regulations… (page 15)
• An increasing number of jurisdictions are permitting advanced practice registered nurses—especially nurse practitioners—to practice independently and autonomously, sometimes in outpatient settings.• In such situations, the operative law for determining what duties nurse practitioners are permitted to delegate to unlicensed allied health professionals such as medical assistants is the nurse practice act and the rules and opinions of the state board of nursing.
• There are many varieties of medical assisting educational programs throughout the United States.• Some educational programs only teach the administrative aspects of medical assisting, and other programs only teach the clinical aspects.• Medical assisting courses are taught at both the secondary and postsecondary levels.• Medical assisting programs at the postsecondary level are taught in community colleges and vocational/technical schools. Such postsecondary academic programs are either: (1) one-year certificate or diploma programs; or (2) two-year associate degree programs.
• There are two accrediting bodies that are recognized by the United States Department of Education (USDE) or the Council for Higher Education Accreditation (CHEA) as programmatic accreditors of postsecondary medical assisting programs: – The Commission on Accreditation of Allied Health Education Programs (CAAHEP); – The Accrediting Bureau of Health Education Schools (ABHES).• Some postsecondary academic programs do not have programmatic accreditation by either CAAHEP or ABHES. Such programs are offered in schools that are institutionally accredited.
• There are two types of academic accreditation: – Institutional accreditation – Programmatic, or specialized, accreditation• Institutional accreditation is a process whereby a school as a whole is evaluated by the accrediting body.• Academic, or specialized, accreditation is a process whereby a particular program or course of study within a school is evaluated by the accrediting body.
• In the strictest sense, only two states require medical assistants to have formal medical assisting education: South Dakota (for all aspects of medical assisting) and New Jersey (just for injections). – Medical assisting in South Dakota is under the joint jurisdiction of the Board of Medical and Osteopathic Examiners and the Board of Nursing: • 36-9B-5 Registration by Board of Medical and Osteopathic Examiners. The Board of Medical and Osteopathic Examiners shall register a medical assistant following the submission of an application by an applicant for registration who has graduated from an accredited school or a school which meets standards similar to an accredited school and has met other qualifications established by the Board of Medical and Osteopathic Examiners and the Board of Nursing.
• Under New Jersey law, only medical assistants who have graduated from a medical assisting program that meets the requirements of the New Jersey Board of Medical Examiners are permitted to be delegated by physicians certain types of injections.
• As is the case with medical assisting educational programs, there are many different medical assisting credentials throughout the United States.• There are medical assisting tests and credentials that are exclusively administrative.• There are medical assisting tests and credentials that are exclusively clinical.• There are medical assisting tests and credentials that measure both administrative and clinical knowledge.
• In almost every states, medical assisting credentials are voluntary national credentials, not mandatory state credentials.• However, increasing numbers of employers and malpractice insurance carriers are preferring, or even insisting, that medical assistants have a credential.• This is due to the fact that employing credentialed medical assistants is evidence that the employer is demonstrating due diligence in hiring medical assistants who have shown a degree of mastery of medical assisting knowledge by the passing of a standardized national examination.
• There are four (4) medical assisting credentials that are accredited by the National Commission for Certifying Agencies (NCCA): – The Certified Medical Assistant [CMA (AAMA)] of the Certifying Board of the American Association of Medical Assistants (AAMA); – The Registered Medical Assistant [RMA(AMT)] of American Medical Technologists (AMT); – The Certified Clinical Medical Assistant (CCMA) of the National Healthcareer Association (NHA); – The National Certified Medical Assistant (NCMA) of the National Center for Competency Testing (NCCT).
• To be accredited by the NCCA, a certification program must have a recertification requirement that requires certificants to furnish proof of continuing knowledge in the field.• To be NCCA accredited, a certification program must also have a reporting mechanism that allows allegations of incompetence or wrongdoing to be brought against the certificants, and an investigation and disciplinary mechanism that can result in revocation of the certification or other measures if the certificant is found negligent or malfeasant.
• The CMA (AAMA) is the only certification program that requires candidates to graduate from a medical assisting education program. Graduation from a CAAHEP or ABHES accredited postsecondary medical assisting program is a prerequisite for taking the CMA (AAMA) Certification Examination.• The CMA (AAMA) is the only certification program that requires proof of current certification in CPR as a requirement for recertification.• The CMA (AAMA) is the only certification program that utilizes the National Board of Medical Examiners (NBME) as test consultant.
• “It is unethical, illegal, and a disservice to the medical assisting profession for medical assistants to refer to themselves as “nurses,” “office nurses,” “doctors’ nurses,” or any other generic term that even remotely implies that medical assistants are nurses.” “Medical Assistants Must not Refer to Themselves as Nurses,” CMA Today, Jan-Feb 2011, Donald A. Balasa.• “Are medical assistants permitted to accept verbal orders from the delegating physician? Medical assistants are permitted to receive and execute orders from the overseeing, delegating, or supervising physician(s) as long as such orders do not require the medical assistant to exercise independent professional judgment in the execution of the orders, or to make clinical assessments or evaluations.” “Frequent Questions about Medical Assistants’ Scope of Practice,” CMA Today, March-April 2012, Donald A. Balasa.
• “Are physicians allowed to delegate patient education to medical assistants? Physicians are allowed to delegate patient education to competent and knowledgeable medical assistants as long as the content of such education has been approved by the delegating physician, and the patient education process does not require the medical assistant to make any interpretive judgments or answer any questions from the patient or patient representative that require a diagnosis, assessment, or evaluation. Medical assistants should not go beyond the patient education information that has been approved by the physician.” “Frequent Questions about Medical Assistants’ Scope of Practice,” CMA Today, March-April 2012, Donald A. Balasa.
• “Are medical assistants permitted to triage patients? In order to answer this question correctly, it is essential that terms be precisely defined and thoroughly understood. In interacting with patients or their representatives—by telephone or in person—medical assistants are allowed to convey verbatim physician-approved information and directions without exercising independent professional judgment or making clinical assessments or evaluations. This communication process is frequently called screening. Communication that does require the health professional to exercise independent judgment or to make clinical assessments or evaluations is frequently called triage. The general legal principle is that physicians are allowed to delegate screening, but not triage, to competent and knowledgeable medical assistants working under their direct supervision in outpatient settings.” “Frequent Questions about Medical Assistants’ Scope of Practice,” CMA Today, March-April 2012, Donald A. Balasa.