Developed by the Minnesota Academy of Physician Assistants.
Revised June 2008
Table of Contents
Introduction page 3
Facts about Physician Assistants page 4
• Scope of Practice
• Spectrum of Practice Settings page 5
• Spectrum of Practice Settings page 5
• Benefits of hiring a PA page 5
• Physician Assistant Registration
in Minnesota page 6
• Prescriptive Authority page 7
• PA Education page 7
• Certification page 8
The Physician PA Team page 8
Cost/Benefit Analysis page 9
• Fee-for-Service Model page 9
• Managed Care Model page 10
• Coverage for Physician Services Provided
by PAs. Page 11
• Billing Under “Incident To” Guidelines page 12
• Updated Hospital Billing Guidelines
Medicare and Shared Visits page 12
• Summary of Medicare Reimbursement page 13
Practice Ownership by Physician Assistants page 14
Medicaid Reimbursement page 14
Private Insurance Reimbursement page 14
TRICARE (formerly CHAMPUS) page 15
Physician Assistants in Hospital Practice: page 15
• Privileging Physician Assistants page 16
• Credentialing Physician Assistants page 16
• Reappointment/Reprivileging page 17
• Information that may be gathered for
credentialing and privileging
of physician assistants page 17
• Medical Staff Membership page 18
Employment Contracts and Agreements page 19
Rural Health Clinic Guidelines
for Physician Assistants page 21
Indian Health Service Employment
of Physician Assistants page 22
Resource Guide page 24
Minnesota Physician Assistant Employment Guide
This employment guide is designed to provide information that will help you
in your efforts to employ or be employed as a physician assistant (PA) in the
state of Minnesota. We have included information about PA education,
scope of practice, reimbursement, insurance, salary and practice settings.
The benefits of having a PA in your practice are listed, as well as
information from independent groups such as the Medical Group
Management Association. (MGMA)
An e-mail link to Minnesota Statute 147A, the statute governing PA practice
in Minnesota, is also included for your reference, as are other links that may
be useful to you.
We encourage you to contact the Minnesota Academy of Physician
Assistants (MAPA) or the American Academy of Physician Assistants
(AAPA) if you have further questions.
Contact information is at the end of this document.
MINNESOTA PHYSICIAN ASSISTANT
FACTS ABOUT PHYSICIAN ASSISTANTS
What is a Physician Assistant (PA)?
Physician assistants are health care professionals licensed (registered in
Minnesota), to practice medicine with physician supervision. As part of their
comprehensive responsibilities, PAs conduct physical exams, diagnose and treat illnesses,
order and interpret tests, counsel on preventive health care, assist in surgery, in
Minnesota, can write prescriptions.
What a physician assistant does varies with training, experience, and state law. In
addition, the scope of the PA's practice corresponds to the supervising physician's
practice. In general, a physician assistant will see many of the same types of patients as
the physician. The cases handled by physicians are generally the more complicated
medical cases or those cases which require care that is not a routine part of the PA's
scope. Referral to the physician, or close consultation between the patient-PA-physician,
is done for unusual or hard to manage cases. Physician assistants are taught to "know our
limits" and refer to physicians appropriately. It is an important part of PA training.
Scope of Practice
Physician assistants work in the context of a physician / PA team to offer a wide array of
services in primary care, as well as specialty areas of medicine including surgery and the
surgical subspecialties. Minnesota Statute 147A.09, Subdivision states “Physician
assistants may perform those duties and responsibilities as delegated in the physician-
physician assistant agreement….patient service must be limited to services within the
training and experience of the physician assistant (or) services customary to the
supervising physician”. A physician assistant works as a member of the medical team
performing duties within the scope of practice of the supervising physician. This
relationship allows for a broad range of services, including, but not limited to:
• Patient histories and physical
exams; • minor surgical procedures
• A variety of diagnostic studies assisting with surgery, ER, acute
to form a diagnostic impression; hospital and long-term care;
• Initiation and management of • family planning, perinatal and
therapies for acute or chronic gynecological care;
health problems; health screens, • referral and follow-up care with
preventative care, physician specialists; and
• patient education and counseling; • issuing prescription orders for
An advantage of employing physician assistants is the ability of PAs to work in a diverse
number of clinical and hospital settings. This is a consequence of the broad medical
training all physician assistants receive, with the flexibility and capability to learn new
areas of medicine as they develop in their careers.
The supervision requirements referred to above allow a PA to practice at sites remote
from the supervising physician, as long as communication between team members is
available for consultation. It is not uncommon for a physician assistant to practice at a
facility some distance away from the supervising physician. The supervisory agreement
also allows for alternate licensed physicians to serve as a supervising physician.
Spectrum of Practice Settings
Physician Assistants can be found in all areas of health care including specialty care. In
clinic settings they perform physical exams, diagnose and treat illnesses, order and
interpret diagnostic tests, and prescribe medications. Hospitals utilize PAs in the
emergency room and urgent care settings as well as members of the hospitalist team. PAs
are part of the collaborative effort in providing timely and high quality care to long-term
care patients in outpatient and nursing home settings. As an integral member of the
surgical team, PAs serve as first assistants during surgery, and perform routine
preoperative and postoperative follow-up care for surgical patients
Physician Assistants are a part of the solution to address the unmet health care needs of
millions of Americans. By working with licensed physicians in a family practice setting,
a rural clinic or as a first-surgical assistant in the operating room, physician assistants
offer an economical and efficient means of delivering high quality health care to many
underserved patient populations.
Benefits of hiring a PA
This broad range of practice settings can help explain the strong demand for physician
assistants and the tremendous growth in the number of practicing PAs from less than
1,500 in 1973 to more than 56,000 PAs today. Medical practice managers and physicians
often cite the following benefits that physician assistants can bring to an organization:
• Better patient flow. PA Education qualifies PAs to meet the unexpected
needs of the clinic setting, including walk-ins, urgent care cases, and routine
follow-up visits such as blood pressure checks and medication reviews.
• Shorter waiting time for appointments. Patients have the option of
seeing the PA when the physician is not available. This leads to greater patient
satisfaction with greater availability of care.
• Greater emphasis on prevention and patient education. PAs are
recognized for their ability to spend time with patients on education, counseling,
and preventative care for problems.
• Ability to extend care into the community. Physician Assistants can
extend care in rural communities, medically under-served communities, and
nursing homes helping to extend access to physician services.
• Enable physicians to focus on difficult problems. Perhaps one of the
greatest benefits provided by a PA is the ability to shift the workload. He or she
can handle routine office visits, freeing physicians to handle more complex or
• Professional fellowship. For solo physicians, especially those in a rural or
frontier setting, a physician assistant can provide a professional colleague that
may otherwise be unavailable.
• Easing physician workload. Achieving greater practice efficiency by
employing PAs is supported by the American Medical Association’s
Socioeconomic System survey, which in 1994 measured the benefits of
employing “non physician practitioners” (NPPs) including PAs, nurse
practitioners, clinical nurse specialists, and certified nurse-midwives. The survey
found that solo practice physicians experienced expanded practice, greater
efficiency, and greater access to care for their patients when they employed a
NPP. Physicians who employed NPPs, were able to work one week less per year
on average, while supplying more hours in office visits and patient care and
increasing net income by 18 percent. Of the four NPP groups in the study, PAs
rated highest in terms of patient productivity and patient acceptance.
• Flexibility Because PAs receive strong clinical education, they are ready to
serve in many health care settings.
• Cost Effectiveness When PAs are fully utilized, the health care system,
institutions and individual practices can realize considerable savings. According
to the Medical Group Management Association (MGMA) PAs generate revenues
covering far more than what their compensation costs employers. According to
MGMA data from 2002, for every dollar of charges a primary care PA generates
for the practice, the employer pays on average, 28 cents to employ the PA. For
surgical PAs that cost is 32 cents.
• Boosting Patient Satisfaction Recent studies by the Kaiser Permanente
Center for Health Research found patient satisfaction levels with PAs high,
ranging between 89 and 96 percent. Aspects of patient satisfaction examined by
the study included interpersonal care, confidence in provider, and understanding
of patient problems. (The Permanente Journal, Summer, 1997)
Physician Assistant Registration in Minnesota
To practice medicine as a physician assistant in Minnesota, registration with the
Minnesota Board of Medical Practice is required. The following requirements for
permanent registration include: 1) current certification from National Commission on
Certification of Physician Assistants; 2) physician-physician assistant agreement,
internal protocol and prescribing delegation (if prescribing authority is delegated)
forms on file; and 3) is not under current discipline as a physician assistant unless Board
considers condition for registration.
Forms for these agreements can be obtained via the internet at www.bmp.state.mn.us.
There are several options for a limited type of registration. A temporary permit is
available to applicants who meet all the requirements for permanent registration and wish
to practice before final approval is granted by the Board. Temporary registration is
valid for a period of up to one year and is available to applicants who have recently
graduated from a physician assistant program and meet all the permanent registration
requirements, but have not yet taken and passed the National Commission on
Certification of Physician Assistants examination. A locum tenens permit is available to
registered physician assistants who wish to practice as a physician assistant in a setting
other than the practice setting established in the physician-physician assistant
agreement. The maximum duration of the locum tenens permit is one year and may be
In Minnesota, statutory authority enabling physician assistants to write prescriptions for
legend drugs was passed in 1991. A license from the Drug Enforcement Agency is
required for prescribing narcotics. The regulatory statute requires the physician-
physician assistant team to review on a regular basis the prescribing practice of the PA.
Physician assistants are educated in intensive medical programs accredited by the
Accreditation Review Commission on Education for the Physician Assistant (ARC-PA).
The average PA program curriculum runs approximately 26 months. The typical
applicant already has a bachelor's degree (64% of entering PA students) and
approximately 4 years of health care experience. There are currently more than 130
accredited programs. All PA programs must meet the same ARC-PA standards.
The relationship between PAs and physicians begins in PA school where physicians, PAs
and others, provide instruction in a curriculum following the medical school model. PA
students typically share classes, facilities, and clinical rotations with medical students.
Because of the close working relationship PAs have with physicians, PAs are educated in
a medical model designed to complement physician training. PA students are taught, to
diagnose and treat medical problems.
Education consists of classroom and laboratory instruction in the basic medical and
behavioral sciences (such as anatomy, pharmacology, pathophysiology, clinical medicine,
and physical diagnosis), followed by clinical rotations in internal medicine, family
medicine, surgery, pediatrics, obstetrics and gynecology, emergency medicine, geriatric
medicine, psychiatry and other elective specialties.
Minnesota has one PA training program at Augsburg College. Thirty-six months in
length, it accepts 28 students a year. The Augsburg Physician Assistant Program was
granted re-accreditation in October 1999. With the class starting in May 2001 the
program became a masters program. Graduates receive a Master of Science in Physician
Assistant Studies and a PA Certificate.
Minnesota is also affiliated with the University of Wisconsin, La Crosse/Mayo PA
program. This program also confers a Masters of Science Degree in Physician Assistant
Upon graduation, physician assistants take a national certification examination developed
by the National Commission on Certification of Physician Assistants (NCCPA). The
NCCPA is an independent organization, and the commissioners represent a number of
different medical professions. It is not a part of the PA professional organization, the
American Academy of Physician Assistants (AAPA). To maintain that "C" after "PA", a
physician assistant must log 100 hours of continuing medical education every two years
and pass the recertification exam every six years.
A number of postgraduate PA programs exist, with specialty training in Dermatology,
Family Practice, Emergency Medicine, Neurosurgery, Oncology, Orthopedic Surgery,
Pediatrics, Psychiatry, Rural Primary Care, Surgery and Urology.
A PA’s education is ongoing after graduation through the continuing medical education
requirements and continual interaction with physicians and other health care providers.
The Physician PA Team
The traditional relationship between PAs and physicians, the hallmarks of which are
frequent consultation, referral and review of PA practice by the supervising physician, is
one of the strengths of the PA profession.1 PAs are committed to the concept of the
physician-PA team. The AAPA has this clearly stated in the AAPA policy on team
practice: The AAPA believes that the physician-PA team relationship is fundamental to
the PA profession and enhances the delivery of high quality health care. As the structure
of the health care system changes, it is critical that this essential relationship be
preserved and strengthened.2 Because they train using similar curriculum, training sites,
faculties and facilities, physicians and PAs develop a similarity in medical reasoning
The Pew Health Professions Commission. Charting a Course for the Twenty-First Century- Physician
Assistants and managed Care. San Francisco. USCF Center for the health Professions.
American Academy of Physician Assistants. 2006-2007 Policy Manual. Alexandria, VA.
during their schooling that eventually leads to homogeneity of thought in the clinical
Other organizations also have policies supporting team practice. In 1995 the American
Medical Association adopted Guidelines for Physician/ Physician Assistant Practice. The
10 guidelines describe the roles of the physician and the PA, including the following:
The role of the physician assistant(s) in the delivery of care should be defined through
mutually agreed upon guidelines that are developed by the physician and the physician
assistant and based on the physician’s delegatory style.
The American Academy of Family Physicians
recognizes the value of team practice. AAFP policy states:
The AAFP recognizes the dynamic nature of the health care environment and the
importance of an interdependent team approach to health care that is supervised by a
responsible licensed physician.
The following tables provide two compelling examples of the financial benefits of a
physician/PA team. Revenues for this analysis are from all professional services,
excluding diagnostic services such as laboratory tests and radiology procedures. Only
certain variable expenses are included, such as salaries and fringe benefits, for a
physician, a PA and medical assistants. Malpractice premiums have also been included.
This analysis has been simplified to clearly show the variability in contribution to
overhead expenses under both a traditional fee-for-service operating environment and
under a 100 per cent capitated payment arrangement.
Financial data for this analysis was drawn from the Medical Group Management
Association 2000 Cost Survey, the 2000 Physician Compensation and Production Survey,
and actual data from various medical practices.
Table I below illustrates the traditional fee-for-service model. Column 1 with a single
physician staff results in a contribution margin of $84,200. Table I, column 2 presents
the same traditional fee-for-service arrangement but includes a physician assistant
provider in addition to the original physician.
(1) (2) (3)
Physician Only Physician/PA Difference
White GL, et al. Physician Assistants and mississippi. J Miss St. Med Assn 1994; 25:353.
Gross charges- Physician $395,000 $395,000 $-0-
Gross charges-PA -0- 211,000 211,000
Adjustments -Physicians (25%) (98,000) (98,000) -0-
Adjustments-PA (30%) -0- (63,000) (63,000)
Total Net Revenue 296,200 443,900 147,700
Salary & fringes-Physician 180,000 180,000 -0-
Salary & fringes- PA -0- 73,600 73,600
Salary & fringes-Medical 25,000 25,000 -0-
Malpractice insurance-Physician 7,000 7,000 -0-
Malpractice Insurance-PA -0- 700 700
Total Variable Expenses 212,000 311,300 99,300
Contribution to Overhead $84,200 $132,600 $48,400
Based on the data presented above, the PA can add $147,700 in net revenue, $73,600 in
salary and fringe benefit cost, a medical assistant at $25,000 in annual cost, and roughly
$700 in malpractice insurance premiums. The net computed increase in contribution
margin as a result of adding a PA is $48,400. The new contribution to overhead for the
two providers has increased to $132,600.
MANAGED CARE MODEL
Table II illustrates a much different environment consisting of a prepaid (capitated) HMO
patient population. Revenue is depicted as fixed payments of $15 per member per month
for the patient panel. In Table II, column I, with a panel of 2,400 health plan members,
total net capitated revenue for the year is estimated at $432,000. Associated variable
expenses are $212,000 leaving a net contribution of $220,000. In column 2, there is an
addition of a PA, but together both providers are still managing the same panel size.
Obviously the contribution will drop commensurate with the additional costs of the PA
and support staff. In columns 3 and 4, the panel is shown to increase by 600 members
each, resulting in increased capitated payments and a higher contribution margin. In
column 4, representing a panel size of 3,600, the contribution has grown to $336,700 or
more than 50 percent of the net revenue.
Managed Care Model
(1) (2) (3) (4)
Physician Phys./PA Phys./PA Phys./PA
(2,400 Panel) (2,400 Panel) (3,000 Panel) (3,600 Panel)
Capitated payments $432,000 $432,000 $540,000 $648,000
Total Net Revenue 432,000 432,000 540,000 648,000
Salary & fringes-Physician 180,000 180,000 180,000 180,000
Salary & fringes-PA -0- 73,600 73,600 73,600
Salary & fringes-Medical 25,000 25,000 25,000 25,000
Salary & fringes-Medical Asst -0- 25,000 25,000 25,000
Malpractice Insurance-Physician 7,000 7,000 7,000 7,000
Malpractice Insurance-PA -0- 700 700 700
Total Variable Expenses 212,000 311,300 311,300 313,000
Contribution to Overhead $220,000 $120,700 $228,700 $336,700
Medicare Coverage for Physician Services Provided by PAs.
The first Medicare coverage of physician services provided by physician assistants was
authorized by the Rural Health Clinic Services Act in 1977. In the following two decades,
Congress incrementally expanded Medicare Part B payment for services provided by PAs
authorizing coverage in hospitals, nursing facilities, rural Health Professional Shortage
Areas and for first assisting at surgery. In 1997, however, the Balanced Budget Act
extended coverage to all practice settings at one uniform rate.
As of January 1, 1998, Medicare pays the PAs’ employers for medical services
provided by PAs in all settings at 85 percent of the physician’s fee schedule. This
includes hospitals (inpatient, outpatient, and emergency departments), nursing
facilities, home, offices and clinics, and first assisting at surgery. Assignment is
mandatory and state law determines supervision and scope of practice.
As of October 25, 2002, CMS issued new rules giving PAs and their physicians
increased latitude in hospital and office billing for E/M services. The new
requirement (Medicare Transmittal 1776) will allow PAs and physicians who work for
the same employer/entity to share visits made to patients the same day with the combined
work of both billed under the physician’s provider number at 100 percent of the fee
schedule. That is, if the PA provides the majority of the service for the patient and the
physician provides any face-to-face portion of the E/M encounter, the entire service may
be billed under the physician.
This new rule does not extend to procedures. The practitioner who does the majority of
the procedure is the one under whom the procedure should be billed. If the physician does
not provide some face-to-face portion of the E/M encounter, then the service is
appropriately billed at the full fee schedule amount under the PA’s PIN with
reimbursement paid at the 85 percent rate.
Billing Under “Incident To” Guidelines
Outpatient services provided in offices and clinics may still be billed under Medicare’s
“incident-to” provisions, if Medicare’s restrictive billing guidelines are met. This allows
payment at 100 percent of the fee schedule if: (1) the physician is physically on site when
the PA provides care; (2) the physician treats all new Medicare patients (PAs may
provide the subsequent care); and (3) established Medicare patients with new medical
problems are personally treated by the physician (PAs may provide the subsequent care).
According to the Balanced Budget Act, PAs (using the 85 percent benefit) may be either
W-2, leased employees or independent contractors. The employer would still bill
Medicare for the services provided by the PA. All PAs who treat Medicare patients must
have a provider identification number (PIN).
Updated Hospital Billing Guidelines
Medicare and Shared Visits
As of October 25, 2002, new rules championed by AAPA give PAs and their
supervising physicians increased latitude in billing for evaluation and management
(E/M) services provided in the hospital setting. Responding to concerns expressed by
AAPA and other medical specialty groups, the Centers for Medicare and Medicaid
Services (CMS) substantially altered its policy involving the coverage of E/M
hospital services when provided jointly by a PA and a physician to the same patient.
The new policy, detailed in Medicare Transmittal 1776, allows E/M services provided
by a PA and a physician in the hospital (inpatient, outpatient, or in the emergency
department) to be combined for billing purposes when delivered to the same patient
on the same day. The combined services may be billed under the name and Medicare
provider identification number (PIN) of the physician at 100 percent of the fee
schedule, as long as the physician provides some portion of the E/M service during a
face-to-face encounter with the patient. The policy also requires the physician and PA
to work for the same employer, practice, or hospital.
This allows PAs and physicians to share visits made to patients with the combined
work of both covered at 100 percent of the fee schedule. That is, if the PA provides
the majority of the service for the patient and the physician provides any face-to-face
portion of the E/M encounter, the entire service may be billed under the physician’s
name and PIN. The new rule does not extend to procedures performed in the hospital.
The practitioner who does the majority of a procedure is the one under whose name
and number the procedure should be billed.
Remember: To combine the professional work done by a PA and a physician, the
following guidelines must be followed:
• The PA and the physician must work for the same employer.
• The regulation applies only to E/M services delivered in the hospital and
not to procedures.
• The physician must provide some face-to-face portion of the E/M services.
Simply reviewing or signing the patient’s chart is not sufficient.
• “Incident to” billing has never applied to the hospital setting – and still
does not apply.
If the physician is not present for any of the face-to-face portion of the E/M
encounter, the service is appropriately billed under the PA’s name and Medicare
PIN, with reimbursement at the 85 percent rate. When billing for hospital services
provided by PAs under the PA’s name and PIN, Medicare does not require the on-
site presence of the supervising physician; access to telephonic communication is
sufficient. AAPA has reimbursement specialists on its staff to answer specific
questions concerning proper billing for services provided by PAs. If you have a
reimbursement problem or question, write to firstname.lastname@example.org.
Summary of Medicare Reimbursement
SETTING REQUIREMEN SERVICES
Office/Clinic when All services PA is legally authorized to provide that
85% of physician’s
physician is not on State Law would have been covered if provided personally by a
Physician must be
Office/Clinic when 100% of physician’s
in the suite of Same As Above
physician is on site fee schedule 1
Home visit/ 85% of physician’s
State Law Same As Above
House Call fee schedule
85% of physician’s
Facility & Nursing State Law Same As Above
85% of physician’s
Hospital State Law Same As Above
First assisting at 85% of physician’s
surgery in all State Law first assist fee Same As Above
Rural Health State Law Same As Above
Reimbursement is All services contracted for as part of an HMO
HMO3 State Law
on capitation basis contract
Using carrier guidelines for "incident to" services.
i.e. 85% x 16% = 13.6% of surgeon’s fee.
Practice Ownership by Physician Assistants
Effective April 1, 2002, the Centers for Medicare and Medicaid Services issued new
Medicare Carriers Manual instructions that expand employment and practice ownership
opportunities for PAs. The new policy removes a restriction on PA ownership by
allowing a PA to have up to a 99 percent ownership interest in an approved corporate
entity (e.g., a professional medical corporation) that bills the Medicare program.
Previously, CMS prevented payment to corporate entities in which a PA had any
ownership interest. Medicare requires that at least one percent of the corporation be
owned by someone other than the PA (e.g., the PAs spouse). There is no requirement for
any degree of physician ownership of the corporation. The new policy also removes a
provision that prohibited Ambulatory Surgical Centers from employing PAs.
In Minnesota, reimbursement under Medical Assistance is 90% of the physician
reimbursement schedule, to those PAs who are registered with the Department of Health
as qualified providers. If the PA is not registered with the Department of Health the
reimbursement is 65%.
Private Insurance Reimbursement
Most insurance companies now credential PAs and billing is done under their provider
number. The reimbursement rate is negotiated in the contract the employer has with the
insurance company. In most cases it is the same rate as the supervising physician.
Private insurers generally cover medical services provided by PAs when they are
included as part of the physician's bill or as part of a global fee for surgery.
TRICARE (formerly CHAMPUS)
TRICARE, formerly know as the Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS), covers all medically necessary services provided by a physician
assistant. The PA must be supervised in accordance with state law. The supervising
physician must be an authorized TRICARE provider. The employer bills for the services
provided by the PA.
The allowable charge for all medical services provided by PAs under TRICARE
Standard, the fee-for-service program, except assisting at surgery, is 85% of the
allowable fee for comparable services rendered by a physician in a similar location.
Reimbursement for assisting at surgery is 65% of the physician's allowable fee for
PAs are eligible providers of care under TRICARE’s two managed care programs,
TRICARE Prime and Extra. TRICARE Prime is similar to an HMO. TRICARE Extra is
run like a preferred provider organization in which practitioners agree to accept a
predetermined discounted fee for their services.
Physician Assistants in Hospital Practice:
Credentialing and Privileging
Although PAs can be found working almost anywhere in a hospital, primarily they
practice in emergency departments (25%), operating rooms (23%), outpatient units
(20%), critical care or intensive care units (4%), and other inpatient units (18%). The
level of physician supervision required is defined in state law and in hospital policy. All
state laws allow the flexibility of off-site supervision by physicians as long as they are
available to the PA via telecommunication. In developing their supervision policies, most
hospitals choose to follow state law; however, they do have the option of being more
stringent (but not less) than the requirements of law. (Federally employed PAs are
governed by federal agency guidelines, rather than state law.)
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) medical staff
standards, that took effect in January 2004, require hospitals to credential and privilege
PAs through the medical staff or by another “equivalent process.”
Prior to January 2004, hospitals had the option of credentialing PAs through the human
resources department and allowing them to practice with only a job description, rather
Bylaws should stipulate that all clinical privileges granted to PAs be consistent with all
applicable state laws and regulations and that a PA may provide medical services that are
within the scope of practice of the supervising physician. More detailed
information about amending hospital bylaws is available at the American Academy of
Physician Assistants web site www.aapa.org, and then by clicking on the PA Licensing
link that leads to the Professional Issues link. A recent update on Hospital Practice and
PAs is available at:
Privileging Physician Assistants
To provide patient care in the hospital, PAs and their supervising physicians must seek
delineation of their clinical privileges. The criteria for granting clinical privileges to PAs
should be outlined in the medical staff bylaws. The bylaws should include a definition of
physician assistant, generally conforming to the definition used in state law and to the
general definition of a PA used by the American Academy of Physician Assistants. An
example might be as follows:
A physician assistant (PA) is an individual who is a graduate of a physician assistant
program accredited by the Accreditation Review Commission on Education for the
Physician Assistant or by one of its predecessor agencies (the Committee on Allied
Health Education and Accreditation or the Commission on Accreditation of Allied
Health Education Programs); and/or who is certified by the National Commission on
Certification of Physician Assistants; and who is licensed, registered, or certified to
practice medicine with physician supervision.
Credentialing Physician Assistants
Hospitals that wish to grant privileges to a PA should verify that the individual is
properly licensed, certified, or registered by the state and has adequate liability insurance.
Credentials verification should include queries of the National Practitioner Data Bank
(NPDB) for malpractice information and the Federation of State Medical Boards (FSMB)
for records of disciplinary actions taken against the PA. The American Medical
Association’s (AMA) Physician Profile Service also offers PA credentials verification.
For a nominal fee, credentialing professionals can confirm a PA’s education program
attendance and graduation date, national certification number and status, current and
historical state licensure information, and AAPA membership status. JCAHO has deemed
that the education information and national certification data are equivalent to primary
source information. To credential PAs, many hospitals adapt their physician forms and
criteria to create a parallel process for PAs. The criteria usually are defined in the medical
staff bylaws or in an associated policy and procedures manual. On demonstration of
satisfactory training and experience, and after approval by the hospital board or
designated individual, a PA may be granted privileges with supervision of a physician(s)
who has appropriate privileges.
As with physicians, hospital bylaws should specify a time period for the renewal and
revision of physician assistant privileges and reappointment to the medical staff.
The medical staff should evaluate information provided by physician supervisors and
physician assistant peers on the PA’s professional performance, including technical and
clinical skills. They also should evaluate information on performance improvement,
including continuing medical education and other courses completed. The PA’s scope of
practice should be updated as changes in clinical privileges are made. Queries to the
NPDB and FSMB should be made any time privileges are renewed, revised, or expanded.
Medical Staff Membership
Medical staff bylaws identify the categories of providers eligible for membership. AAPA
believes that PAs should be members of the medical staff because they provide medical
care. While their authority to provide care is delegated by a supervising physician, PAs
exercise a high level of decision making and autonomy in day-to-day practice. The
AAPA recommends that medical staffs credential and privilege all PAs and include them
as members, with all of the committee involvement, quality measures, and peer review
that are part of medical staff oversight. Both Joint Commission standards and Medicare
and Medicaid Conditions of Participation for Hospitals allow PA membership on medical
staffs. For a review of Minnesota statutory regulations regarding staff membership, refer
AAPA’s publication, Physician Assistants and Hospital Practice, offers a sample
application for PA clinical privileges and detailed information about hospital bylaws, PAs
and EMTALA, relevant Joint Commission standards, and more. The publication,
providing nuts-and-bolts tools to ease the process of credentialing and privileging PAs, is
available to AAPA members for $25 and to nonmembers for $50. Copies may be ordered
online at www.aapa.org/aapastore or by calling 703/787-8044.
American Academy of Physician Assistants
Department of Government & Professional Affairs
950 North Washington Street
Alexandria, VA 22314-1552
Employment Contracts and Agreements
In most instances, a written agreement is presented to the employed physician assistant
outlining the key terms of his or her employment status. This agreement may be in the
form of an employment contract or may be less formally drafted in a “letter of
employment”. However written, the following key areas are commonly addressed within
the employment document:
Job Description Insurance
Scope of practice Malpractice insurance, including “tail
Physician supervision Health/dental insurance
Administrative responsibilities Life/disability insurance
Hours of operation Professional Expenses
Expected hours per week CME paid time off
Call schedule CME program and travel costs
Holidays/weekends Membership dues to state and
national professional associations.
Certification expenses: CME logging
and NCCPA fees.
State registration; DEA licensing;
Compensation Package Contractual Provisions
Base salary Effective date
Bonus arrangement Probationary period
Annual salary adjustment Renewal
Pension/retirement benefits Termination provisions
Paid time off Notifications
The above items represent basic areas of employment that should be clarified when the
PA, employer, and the supervising physician discuss the terms of employment. It is
advisable to have a written contract or practice agreement that clearly spells out the terms
Rural Health Clinic Guidelines for Physician Assistants
Rural Health Clinics (RHC) are located in areas designated by the Bureau of the Census
as rural and by the Secretary of the Department of Health and Human Services or the
State as medically underserved. Section 410 of the Medicare Prescription Drug,
Improvement and Modernization Act of 2003 states that for services furnished on or after
January 1, 2005, professional services provided by physicians, physician assistants, nurse
practitioners, and clinical psychologists who are affiliated with RHCs are excluded from
the skilled nursing facility prospective payment system, in the same manner as such
services would be excluded if they were provided by individuals not affiliated with
To qualify as a Rural Health Clinic, a clinic must be located in:
A non-urbanized area AND ONE OF THE FOLLOWING:
A medically underserved area;
A geographic Health Professional Shortage Area (HPSA); or
A population group HPSA.
Any area that is not defined as urbanized is considered non-urbanized. The U.S.
Census Bureau defines an urbanized area as a central city of 50,000 or more and its
A RHC must also:
Employ a midlevel practitioner 50 percent of the time the clinic is open;
Provide routine diagnostic and laboratory services;
Establish arrangements with providers and suppliers to furnish medically necessary
services not available at the clinic; and
Provide first response emergency care.
RHCs provide the following:
Services and supplies incident to the services of physicians;
Services of nurse practitioners, physician assistants, certified nurse midwives, clinical
psychologists, and clinical social workers;
Services and supplies incident to the services of nurse practitioners, physician
assistants, certified nurse midwives, clinical psychologists, and clinical social
Visiting nurse services to the homebound;
Services of registered dietitians or nutritional professionals for diabetes training
services and medical nutrition therapy; and
Otherwise covered drugs that are furnished by, and incident to, services of physicians
and nonphysician practitioners of the RHC.
Payment for RHC services furnished to Medicare beneficiaries are made on the basis of
an all-inclusive rate per covered visit with the exception of pneumococcal and influenza
vaccines and their administration, which are paid at 100 percent of reasonable cost. A
visit is defined as a face-to-face encounter between the patient and a physician, physician
assistant, nurse practitioner, certified nurse midwife, visiting nurse, clinical psychologist,
or clinical social worker during which a RHC service is rendered. Encounters at a single
location on the same day with more than one health professional and multiple encounters
with the same health professional constitute a single visit, except when the patient suffers
an illness or injury requiring additional diagnosis or treatment subsequent to the first
encounter. Payment is made directly to RHCs for covered services furnished to a patient
at the clinic or center, the patient’s place of residence, or elsewhere (e.g., the scene of an
accident). Laboratory tests are paid separately.
A RHC cannot be concurrently approved for Medicare as both a Federally Qualified
Health Center and a RHC.
Information above from: www.cms.hhs.gov/MLNProducts/downloads/rhcfactsheet.pdf
Indian Health Service Employment of Physician Assistants
The IHS does not require PAs to be licensed in the State(s) in which they will be
performing their official duties. Based upon Federal sovereignty and supremacy
principles, a State may not require that an IHS employee who provides health care within
the State as part of his or her Federal duties be licensed in that State. However, Drug
Enforcement Administration regulations require the PA be authorized to prescribe
controlled substances by the jurisdiction (e.g., State) in which he/she is licensed,
registered, or otherwise specifically recognized to practice his/her profession.
Physician Assistants who were hired prior to February 1, 1990, may remain in their
present positions without certification; however, they must become certified in order to
transfer to a new position.
Licensure: Health care professionals who are employed
by the IHS are required to be licensed, registered, or
nationally certified. Physician Assistants employed by
the IHS must be nationally certified (unless exempted).
Prescribing Privileges: Prescribing privileges that may include prescribing all classes of
pharmaceuticals, shall be included in the PA medical staff privileging
process. All privileges shall be granted based on the PA’s education and clinical
experience. Prescribing privileges include writing prescriptions, privileged inpatient chart
orders (if so dispensing of medications as may be required in remote settings), and the
administration of pharmaceuticals, where appropriate to do so.
Prescribing privileges for Drug Enforcement Agency(DEA) Controlled Substances
(Schedules II-V) may be granted to PAs in accordance with the Indian Health Manual
Part 3,Chapter 7, a Pharmacy, Section 3-7.3D (2a), dated 6/26/95:
a. The facility has authorized the PA to dispense or prescribe designated Schedules of
Controlled Substances under its DHA registration.
b. The PA-must be registered, licensed; or otherwise specifically recognized by any
State as having authority to prescribe designated Schedules of Controlled Substances.
c. The PA adheres to all local facility policies regarding-the prescribing of controlled
The implementing regulations of the Controlled Substances Act-Title 21, CFR, Section
1306.03 state (in part): “A prescription for controlled substances may be issued only by
an individual practitioner who is authorized to prescribe controlled substances by the
jurisdiction in which he is licensed to practice his profession.”
The preceding information is taken from the Indian Health Service Circular No. 96-02
and may be accessed at the following web address: www.ihs.gov/PublicInfo/Publications/
Minnesota Academy of Physician Assistants
600 S. Hwy 169, Suite 1680
St. Louis Park, Minnesota 55426
Phone: 952 562-8700
Fax: 952 542-0130
MAPA 2007 Membership Survey
American Academy of Physician Assistants
950 North Washington Street
Alexandria, Virginia 22314-1552
Phone: 703 836-2272
Fax: 703 684-1924
Minnesota Board of Medical Practice
University Park Plaza
2829 University Avenue SE Suite 500
Minneapolis, Minnesota 55414-3246
Phone: 612 617-2166
National Association of Rural Health Clinics
National Association of
Rural Health Clinics
200 10th Street
Des Moines, IA 50309
National Rural Health Association
National Rural Health Association
One West Armour Blvd.; Suite 203
Kansas City, MO 64111-2087