Featured Questions

Is there a law that prohibits NPs from working for competing clinics? I would like to work for a pediatrics clinic part-time and a family practice clinic part-time.

There is no law. Many NPs work for multiple clinics or physicians. You just have to make sure that you don't sign a contract that states you cannot work for another provider.

A patient will often present with a complaint that initially seems within scope. While obtaining the HPI or performing the PE, something will be revealed that makes the patient out of scope midway through or towards the end of the visit. For example, a patient will present with generalized foot or ankle pain that they suspect is a sprain (something that we treat), and then during the exam the clinician will become suspicious for a fracture. Since we do not have X-ray available on site and do not treat fractures, they are now considered out of scope and we then refer them to one of our urgent care clinics with x-ray services down the street (all within the same health system).

There has been debate amongst the clinicians on whether we can or should bill for these visits. Since a chief complaint, vitals, PMH, PSH, HPI, and partial or full exam have been completed, most argue that we should certainly bill, although we are charting "out of scope, refer to urgent care now for further evaluation and treatment" as our plan of care at the end of note, along with a generalized diagnosis like "ankle pain" or "foot pain".

From a medical, business, and legal perspective, what is appropriate? May we bill for these medical work-ups that then reveal themselves to be out of scope only halfway through or towards the end of the visit? And what do you recommend regarding documentation of these encounters?

If you do an assessment on the patient, you can bill for the patient. For example, the one you gave, the patient comes in thinking it is nothing serious and you believe after assessment, it may be a fracture. You refer. You can bill for the patient's visit as long as you document everything you have done for the patient that warrants referral. For example, I work as a PMP at a community clinic. I frequently see children that need referrals for various reasons. I document my assessment and why I am referring the patient. To my knowledge, we have not had problems with reimbursement.

We do drug screening in our pain care which we use to determine appropriate use and inappropriate substance use. Recently, pharmacists are requiring we increase screening on certain patients which they name. They are wanting one of two responses about the results - "appropriate" or "not appropriate". This information is being shared without a specific release of information being signed. Is this a HIPPA violation? I wonder if the information might be used to press for criminal charges by the pharmacy, DEA, or others. Also, what is the clinic’s responsibility with these results as they might relate to suspicion of criminal activities?

Are the patients aware that the pharmacist is asking for an increase in screening? The pharmacist can advise the provider what to do but cannot order them to do it. The provider is the one who decides what is necessary for the patient. Are you part of CURES? That will identify if the patient is seeking drugs from multiple providers. Otherwise, the patient should be signing a release to provide the pharmacist the information.

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