Collaborative agreement details allied workers' duties

Recently a physician asked me to review a proposed collaborative agreement between his practice and an advanced-practice nurse who was hired to treat patients during extended office hours and at off-site locations, including hospitals and extended care facilities.

Collaborative agreements typically set forth the conditions and qualifications in the contractual collaborative relationship between the practice group and an ancillary service provider, which might include a nurse practitioner, physician assistant or certified registered nurse anesthetist.

Many states have regulations that specifically govern such collaborative relationships. Such regulations often address clinical practice, including medical direction, supervision, consultation and prescriptive authority.

The written collaborative agreement should also address the services the collaborating physician generally provides to his patients in the course of his practice, and the medical direction that shall be provided to the ancillary service provider.

The physician group practice I represent had recently hired the nurse practitioner, and an employment agreement was signed by both parties. The nurse practitioner gave my client a copy of a collaborative agreement that she previously had executed with a hospital. The contract appeared to be the standard collaborative agreement that the hospital executed with all of the ancillary service providers who delivered patient care at the hospital and its related entities.

During my review of the proposed collaborative agreement, I noticed that the contract contained boilerplate language that broadly addressed the collaborative relationship between a hospital and ancillary service providers. I drafted a collaborative agreement to protect the interests of the practice group, and this agreement contained language that specifically defined the collaborative relationship between the practice and nurse practitioner.

This column will focus on some of that specific language, including issues that are related to scope of practice, medical direction, insurance and documentation.

Scope of practice. The scope-of-practice provision should clearly delineate the specific duties of the nurse practitioner and include language that the nurse practitioner meets all of the requirements of the state practice act and has completed the applicable educational requirements for licensure. In my client's agreement, the nurse practitioner will work with the collaborating physicians of the group practice to deliver health care services to patients who are acutely and chronically ill.

The agreement I drafted set forth the written protocols the group has established as well as the protocols governing the nurse practitioner's services at the local hospitals and extended-care facilities. I also included a provision stating the nurse practitioner shall maintain allied health privileges at the hospitals for the designated services.

You also might consider including language stating that the written collaborative agreement shall be reviewed and updated annually, or in conjunction with any changes to the state practice act and licensure requirements.

Some states require collaborative agreements to be on file at all sites where the ancillary service provider delivers patient care services. Make sure you check your state regulations to ensure compliance with any such requirements.

Medical direction. Consider including a provision setting forth the parameters of the medical direction that shall be given to the ancillary service provider. If the collaborative agreement delegates prescriptive authority to the ancillary provider, make sure that such authority is spelled out in the contract and complies with all state and federal regulations.

Insurance. In addition to ensuring that the ancillary service provider has the appropriate licensure, you should also make sure that your practice and the collaborating professional have the appropriate insurance coverage. The employment agreement will most likely address the insurance terms, payment, and which party is responsible for continued coverage upon termination or expiration of the employment agreement.

You should consider referencing the insurance terms in the collaborative agreement. You should also ensure there is appropriate coverage for all sites where the ancillary service provider shall be providing patient care on behalf of your practice.

Documentation. It is imperative that the nurse practitioner provide documentation for purposes of regulatory compliance, claims submission for receipt of payment, and to avoid unnecessary exposure to any potential liability. Make sure that you carefully review and discuss your expectations regarding documentation with the ancillary service provider prior to the delivery of health care services to your patients.