Podcast Recap – The Collaborative Physician and APP Relationship

In this inaugural episode of our podcast, and of the “Lessons from Litigation” series, join host Signe Monson from CoreMedSource, along with guests CoreMedSource CEO, Dr. Debra Shelby, PhD, DNP and Dr. Paul Rose, MD, as they delve into the critical dynamics of the collaborative relationship between physicians and advanced practice providers. This episode serves as a pivotal guide for navigating the complexities of legal risks in healthcare practices.

About Our Guests:

• Dr. Debra Shelby brings over 30 years of experience as a board-certified PhD, DNP prepared dermatology nurse practitioner, with a rich background in critical care, surgical, and plastic surgery nursing. Dr. Shelby has been offering her expertise as a legal consultant and expert witness since 2002.
• Dr. Paul Rose, a board-certified dermatologist and hair restoration surgeon, has amassed over 30 years of medical experience, including emergency medicine. After obtaining his law degree in 2005, Dr. Rose has been leveraging his legal knowledge in providing consulting and expert witness services.

Episode Highlights:

• The Rise of Paraprofessionals: The significant increase in the utilization of paraprofessionals within the medical field, such as physician assistants and nurse practitioners, and the legal considerations that accompany this trend.
• Training, Scope of Practice, and Legal Implications: The varying training paths of physician assistants and nurse practitioners, the standardization of curriculum, and the resultant scope of practice. We explore how these factors can lead to legal challenges and the importance of clarity in roles and responsibilities.
• Delegation, Supervision, and Documentation: The legalities surrounding the delegation of medical tasks, the necessity of proper supervision, and the critical role of accurate documentation and informed consent in mitigating legal risks.
• Billing Practices and Legal Accountability: A key focus of the episode is on the intricacies of medical billing, specifically “incident-to” billing, and the legal obligations of advanced practice providers in ensuring compliant billing practices to avoid fraud and malpractice allegations.

Key Takeaways: This episode emphasizes the importance of understanding and adhering to legal requirements in the collaborative practice between physicians and advanced practice providers. It highlights the need for comprehensive training, proper delegation and supervision, meticulous documentation, informed consent, and ethical billing practices as fundamental elements to reducing litigation risks in healthcare.

Transcript from the show:

Signe Monson:
I know you guys have some great insight on this topic. I know you’ve got a lot to say and a lot of advice. We’re looking forward to hearing your insights on this. It’s really a pivotal relationship – and you’ll be what, exploring the nuances, the protocols – and we’re just looking forward to hearing your advice on effective strategies to maneuver this successfully.

Paul Rose:
I think this is a very interesting topic. Over the last couple of decades, the use of paraprofessionals within medicine has increased tremendously for a multitude of reasons. But with that change in how medicine is provided come certain legal aspects that need to be considered.

I think this is an important topic to discuss today. And I think one of the areas, the first area that I think perhaps we should discuss is the use of physician assistants and nurse practitioners, trying to understand how they’re trained and how they’re best utilized within a medical practice and what some of the legal hazards are for a physician or medical practice utilizing such paraprofessionals.

And I can’t think of anyone better to speak about that than Dr. Debra Shelby, who is a doctorate in nurse practitioner.

Debra Shelby:
That’s a really cool saying, Paul. Is that para provider or something like a cool paratrooper? Do we like, do cool things like that? We parachuted onto medicine in a very cool way, I’m going to say. So yes, advanced practice providers and physicians, really the healthcare team, so important.

Paul Rose:
Well, you certainly parachuted into the podcast.

Debra Shelby:
And we work together on a daily basis. And often, as I have been doing medical malpractice consulting, I think to myself, what could we have done as consultants so that these things don’t continue to happen? And what we’re going to talk about today are some simple things that clinics, physicians, advanced practice providers can do to really help reduce their risk.

And not saying that it’s going to prevent malpractice suits. Anybody can bring forward a medical malpractice suit against you. Nothing is going to prevent that, but reducing the risk and really doing well when you go through that discovery period is crucial and the outcome.

Paul Rose:
I was wondering, Debra, if perhaps you can talk about the difference in training between a physician assistant and a nurse practitioner and the ramifications of that in terms of perhaps state medical boards and how things can vary so much between one state, if we’re talking about the United States, and another state. This is, of course, different in other countries, and that’s a whole other discussion. But perhaps you could elucidate on the difference so that people can understand what the realm of practice is, the scope of practice, and who governs the scope of practice for these people.

Debra Shelby:
Well, I’m going to start with the easiest and that would be the physicians and the physician assistants. And I believe I’m going to use the physician assistant/associates. I’m not sure if that terminology has been passed or not, but they have a pretty standardized curriculum nationally, which makes it much easier for the patient to recognize training. They may not understand exact nuances of the training, but a PA in Florida is basically trained the same way under the medical model as the PA in California. Now scope of practice might be different. So scope of practice for a physician assistant typically falls under the board of medicine. I know in New Mexico we also include the board of pharmacy, and where it becomes a little bit cloudy is actually with nursing. Nursing has changed so dramatically and some for the good and some for the not so good. And it can be very confusing. This doctor of nursing practice, the way it first came on site was a little bit different than what it has morphed in today. So when we’re talking about a doctorate of nursing practice, there are different concentrations that a nurse can pick and also there are different types of entry level. So typically, the master’s nurse prep, the master’s prepared nurse practitioner comes on the scene with years of experience. That was the typical entry point. And then they get their DNP. Now, as time has gone forward, now we have these bachelor of nursing programs that go into the DNP. And so they come right out of school and going into this advanced practice role.

Debra Shelby:
I’m not sure how I feel about the bachelor’s into DMP. I think it has some issues. Again, nursing typically will go from an associate’s to bachelor’s to a doctorate. The physician assistant comes in with a bachelor’s degree and that bachelor’s degree can be in any science. They can, it doesn’t have to be, it could be bachelor’s in chemistry, biology, and then they go into a PA program. Nursing again, typically nursing is across the board, associates up to the doctorate. So as far as assessment skills, as far as training, I think that can vary from provider to provider in somebody that’s coming out of a nursing program.

And when I say things have changed for the not so good, I think these online programs that are out there are really pushing forward many nurse practitioners with no oversight of what their clinical experience is. And you know, Paul, that training, you were trained by experts in your field, I have been trained in experts in my field, world-renowned people, and so we were very fortunate.

But there are many nurse practitioners who really sometimes just get a shadowing experience and they have to find their own clinical preceptors. So this is a little bit of a danger area in nursing as far as are we all created equal? No, we are not. That is the unfortunate truth. And so when in my clinical setting, I have all of my patients sign my bio. I want them to know what my clinical training is, what my degrees are in, what my clinical foci was, and my concentration. So I think, again, with scope or practice, answering that question, the state of Florida can be a little bit confusing. I have a license there. I actually have autonomous practice in Florida, but that’s for primary care. It is not for specialty care.

So again, it could be a little confusing when we say we have independent practice because it’s not independent practice when you’re dealing with a specialty. And I think physicians get a little confused because heck, if nursing and nurses are confused about our own training, how is a physician going to know where we come from, what our degree of training is? And I think that a podcast like this is very important for the collaborating physician to listen to, to reach out, reach out for consultants like what we do, how we come into practices, and we help them reduce their liability. But I’m taken aback when a physician really doesn’t dive into what the actual training was of a nurse practitioner or a physician assistant before bringing them on board and then putting them into a satellite office and having a great reduction of oversight. And when we’re talking about those types of relationships, we could have general supervision or direct supervision. We can have that collaborating relationship, or you can have a physician who is there as a consultant or part of the practice, and really in an independent state, there could be a physician within that practice, but there’s no collaboration, there’s no consulting, there’s no liability on their part. So I think there needs to be a clarity. And again, here in New Mexico, it’s completely independent. We do report to also the Board of Pharmacy, but nursing can either solely report to Board of Nursing, or they can report to the Board of Medicine, and nursing or like I just pointed out, all three, pharmacy, medicine and nursing.

Paul Rose:
Well, I think your comments speak to some of the legal concerns that or hazards that can occur when physicians are involved with physician assistants or nurse practitioners or even other personnel. And it gets to the question of delegation of services. So what can a physician delegate? What procedures can a physician delegate? What examinations can a physician delegate?

And there’s a great deal of confusion about this from a legal standpoint. So it’s imperative that a physician understand within his or her medical board what the statutes are and what those statutes say in terms of what defines supervision, what defines being on the premises, what defines being within phone contact. In some states, just being available by phone can be suitable. In other states, the physician has to be on the actual premises. And in some states, may not have to be there at all, but there often is some sort of agreement between the paraprofessional and the physician. And that’s also important for the patient to understand the role of the physician assistant, the role of the nurse practitioner within the medical practice, and how that affects the patient, even to the extent of how billing is done for the patient’s services that are rendered. One of the points that I think is important is that physician assistants are trained differently than nurse practitioners are. And the, at least traditionally, physician assistants, as I understand it, would do a two-year program, and their background might vary tremendously.

And they often had very limited clinical exposure, and most would wind up in primary care. But as aesthetic medicine has become so overwhelming within the medical practice area, many of them are trying to get into aesthetic practice and leaving behind the very clinical primary care medicine that they were perhaps trained in. Some of them have trained in very specific niches whether it’s cardiovascular or orthopedics. So their scope is very limited as to what they’re able to do. Nurse practitioners as you pointed out historically had a great background in clinical care and for them to come to the practice, the point of a practice, they brought with themselves a great deal of experience. But as you noted that is changing in some respects. Some people can go through getting their BA and then going immediately onto their doctorate. And then I think that severely limits what their clinical experience is, and that severely changes the legal outlook when one is involved in a malpractice case. And maybe you have seen some cases where the training of the physician assistant or nurse practitioner is questionable. I think one of the first things we do as expert witnesses in reviewing cases, is trying to understand the training of all the practitioners and non-practicing personnel within that physician’s practice.

Debra Shelby:
I agree. I, when I speak with my students about their training and I’m also going to speak out to the physicians, I implore you to please write down your training, write down, keep a formal log. The first thing as you pointed out is that as an expert witness, the first thing we’re going to ask for is your education, your training. Then we’re going to look for your certifications. If you’re practicing dermatology and it’s over five years or past your board eligibility and you have not received your certification, why? And when you have to face, I’m the nicest person in the world, but you get me into my deposition and you have to face me on a plaintiff’s side, it’s not pleasant. And most of my cases don’t go past depositions because of this very reason, most cases will be made or broken in this discovery deposition period where the attorneys are actually trying to figure out, do we have a strong case? Do we not have a strong case? And so education is probably a primary factor that will help really push a case forward or maybe settle quickly. Here’s an example, Paul, dermoscopy. Everybody’s on this bandwagon with dermoscopy. And I think it’s great. Patients come in, they sit there, and they say, where’s your dermatoscope? And my answer is, I’m old school. I look, I have magnifying glasses, but my answer to that and to many people that our training is if I have to look at something that closely, I’m going to biopsy it because the most definitive answer to a diagnosis is going to be that pathology. Now, if you’re one of these weekend warriors that you’re going and taking these dermatology courses and then you’re going and looking at these lesions and saying, oh, I looked at this lesion and it was okay. Well, again, this training is going to be crucial. Did you have a clinical log showing that you spent so much time with a dermatoscopy expert, really fine tuning this basic skill that you need to be confident in using that tool. So be cautious with things that you’re doing or learning on the weekend. I know back in the day, I mean, you and I have go back years. So we’ve been in medicine quite some time. I mean, again, back in the stone age, where…

Paul Rose:
I still have a Pet T-Rex.

Debra Shelby:
Yes, right? So we practiced in the Stone Age, we did written notes, and we didn’t have all these new gadgets that are coming out. We use on our diagnostic skills, our good clinical judgment. It seems like medicine is just starting to turn into this algorithm of computerized AI assisting medicine and really not relying on good clinical judgment. And so again, training can bite you in the derriere. And so you have to really be cautious about learning new skills and you have the didactic part of training and then you need to have that clinical part of training. And so, again, I always say you won’t get sued for doing a biopsy. You will get sued for not doing a biopsy. So be cautious. These things are tools.

Paul Rose:
And to your point, I think that, you know, I often tell medical students and residents, it’s more important to know what you don’t know than what you do know. You’ve got to understand where your training is lacking and not try to be overzealous in what you think your skills are. So I think demoscopy is a very good example of that because one could imagine in a lawsuit where a physician is using, or nurse practitioner or PA is using, a dermatoscope and judges that this lesion is benign but then for some reason it turns out that perhaps the lesion was let’s say a melanoma, well did you take a picture of it do you have documentation at the time that you looked at it that we can look at this moment in the deposition or at trial that shows the characteristics that would go along with a dermatoscopic examination that substantiates what you thought you saw because now you don’t have a picture, whereas most dermatologists are going to default ultimately to the biopsy because as you noted, with the biopsy you have a specimen in hand, you have a slide, you have a reading done hopefully by a board-certified dermatopathologist. You have something substantial there. So with dermoscopy, there is, especially to an untrained eye, or not an adequately trained eye, there’s a great deal of risk there, ultimately, especially, let’s say, a primary care person doing that. They don’t have the training behind them to back up necessarily what they think they’ve seen. And so I think the legal aspect of that is really quite important for physicians to understand.

And that brings us to another point in my mind, which is when a physician allows a paraprofessional to do certain things, in most states, the physician themselves must be competent in that procedure themselves to be able to supervise the paraprofessional. And what we’re seeing today is many physicians being attracted to adding things to their practice that they themselves don’t know how to do, such as hair transplantation. And so they bring in, let’s say, a robotic machine to do it, and they have a technician doing it, or the PA, or the nurse practitioner, but the physician doesn’t themselves know how to actually do a hair transplant. If something goes wrong, there’s going to be a problem, and that brings in another factor, which is did the physician notify the malpractice carrier that they were going to add this to their practice. Is there enough training material to show that the nurse practitioner, the PA, the technician had adequate training to do this? So it opens up a whole realm of legal threat. I don’t know what your thoughts are on those kinds of events.

Debra Shelby:
I completely agree with you. And going back to that relationship between the physician and the advanced practice provider. So there’s a lot of physicians who don’t even know that they’re supposed to send a letter, like in the state of Florida, you’re supposed to register yourself and that relationship with the Board of Medicine. And if you miss that step, that, again, that is that time of discovery that’s going to be an issue with oversight. And then of course, review your protocols. And you said, well, what can a nurse practitioner and a PA do? Well, most scope of practice are basically written to be very general and vague. And their scope of practice or our scope of practices, anything that we’re formally trained to do.

And in a collaborating physician role, you need to make sure that you are comfortable with the skills of that nurse practitioner and PA and review those protocols and have those conversations. You know, it’s one of those things, you and I have been working together for so long. We talked all the time when we were in clinical practice together.

We would call each other, we would talk with each other, we were on site with each other, but it was this daily thing that we would wake up and we would call each other, and you would reach out to me and if there was a difficult case when I was in my, especially in my first five years, you need that support. So when we do these dermatology training programs, as a program director at FAU for the Derm program, I always say this program is about giving you foundations. This program is not about you going out and opening up independent practice. You need five years to feel comfortable. And to me, dermatology, for example, I’ve been doing it, like I said, doing this for years. And so I know when I first started feeling comfortable in practice was probably around that five year mark. But dermatologists don’t just start signing the paper. They should be going over protocols saying, you know, what, what can we do to increase your skills? What kind of classes do you need? Let’s bring some lectures in be a continuum of education for these advanced practice providers. But not just for them. As a dermatologist, medicine is changing so quickly. There’s many dermatologists who don’t stay on top of the newest medications, new drug therapies. They’re still practicing in their old ways. And biologic immunotherapy has taken a forefront in medicine all across the board. And so I try to explain even to dermatologists when you’re not prescribing medications like biologics, like psoriatic biologics, psoriatic medications, and you’re not offering those patients and staying on top of these medications so that the patient gets the best, most current treatment, and then you’re giving them topicals for years, and now all of a sudden the patient has psoriatic arthritis because you did not intervene with this patient early enough, that can set you up for a malpractice case. So when we talk about training and staying on top of your training, it’s not just for advanced practice providers. It’s also for physicians. So physicians really, again, listen clearly, just because you have that MD and a dermatology residency doesn’t mean that you’re staying on top of your game. You’re supposed to be at the head of the healthcare team. Stay at the head and make sure that your team members are there with you.

And there’s only one standard of care, right Paul? One standard of care. You don’t have two standards of care for an advanced practice provider and a physician. Patient outcomes are determined by the correct care, the correct treatment plan. And so that correct treatment plan needs to be things that are going to basically help the patient in, we’ll use the autoimmune diseases, reduce and help try to prevent debilitating disease. So when I get a case on a patient who is suing for a disease that they would fail to get a treatment modality, and the physician themselves, as you brought up, are not capable, are not keeping up with their skills they are brought in to that malpractice situation because they need to be completely active in all patient care within that clinic. And so they may not have to see all the patients, but in some sort of way, you need to be checking with your team and making sure that they are comfortable with the patients and the acuity level that they’re seeing. And if not, they need to intervene.

Paul Rose:
Well, I think your comment about a standard of care are really crucial because traditionally in law, people have wondered about local standards of care versus national standards of care. And in most instances, I would say that we look to national standards of care. What’s happening around the country? What’s happening at the majority of places where these techniques are being utilized as opposed to a local standard. And it also relates to informed consent because if the physician isn’t aware of what treatment modalities are actually available because the physician has not kept up with things, then there’s a question about was the patient adequately informed. And you know, to touch a patient, to deal with a patient without adequate informed consent and who gives informed consent in most states, it’s important that the physician themselves give the informed consent because without that you run the risk of assault and battery and those can be criminal charges especially when it’s done by non-professional people, I mean I’ve been in situations where I’ve reviewed a chart where the informed consent was given by a secretary. It’s really sort of ludicrous to ask a secretary to provide informed consent to a patient, in my opinion, and that’s a personal opinion, but I mean, it really puts you in legal jeopardy in some situations. And it’s important, since we’re using paraprofessionals and technicians doing things that they’re not necessarily trained to do, at least from a certification point of view, it’s important that the patient understand that the person working on them may or may not have a medical degree in what they’re doing. Or the patient needs to know that the person working on them doesn’t carry malpractice insurance. Has the physician indicated to the patient that, by the way, Sally here is going to be doing your hair restoration procedure. She’s going to actually be incising into the back of your head with this drill and I’m going to leave the premises and go to lunch and she’s going to be working on you. You know, patients need to know what they’re getting, they have a right to know what they’re getting into and I dare say that there have been situations where physicians haven’t even been on the premises when a surgical procedure is being undertaken. And this has occurred a lot of times with hair restoration procedures. So there are real dangers here.

Debra Shelby:
Yeah, I, you know, absolutely. This is a pet peeve. Well, I have many pet peeves, I’m going to admit. But this is a big one. If you just want to write a check and let’s just call it a day, go ahead and let your secretary give informed consent. Because again, there is legislation on actually who can give informed consent. So typically, it’s the person must be involved in the procedure first and foremost. But secondly, you have to either be a nurse practitioner, PA or physician. And so again, the secretary can witness the signature. I think that’s where a lot of people go wrong is that little witness line there is just basically witnessing that the person signed. And so I love it when physicians say, I can delegate, you brought this really good point up. You have to be very cautious with delegation and who you’re delegating to. Board of Nursing specifically is very clear on who you can delegate to. And remember this new thing with independent practice, now we have nurse practitioners and physician assistants calling themselves medical directors. So be very cautious about being a medical director and who you’re allowing to actually do procedures underneath your license. Let’s be clear, they’re under your license because you are overseeing these unlicensed professionals. So if you think as a physician that it’s okay to allow your medical assistant to suture and close wounds, well, you’re wrong.

I knew a dermatologist that would hire waitresses from Applebee’s and bring them into their office and teach them all kinds of crazy stuff. And I would just, you know, they wanted to hire these pretty young things to be in their office. And I said to them, you’re allowing them to suture? Yeah, I can do whatever I want. No, you cannot. So go ahead and keep doing these bad medical decisions and just make sure you have that hefty checkbook to start signing off on your settlement cases because that’s exactly what’s going to happen if when you continue to train unlicensed people to do skills that they are not licensed to do.

Paul Rose:
So you and I practice in jurisdictions where I think that’s generally the case as to how delegation is limited. But I have to say there are some states where the statutes are so unclear that it’s theoretical that a physician, and some of them actually do it, can allow a person off the street to be directed to do something. And one could imagine especially in a rural area, that a physician who’s, let’s say, delivering a baby might require the assistance of a non-medically trained person because of an emergency to do something which involves a medical task, surgical task perhaps. And so there are exceptions to the rule. And again, it can vary tremendously from state to state. It’s a little bit uncomfortable for me to hear about some states where apart from emergency situations where this is going on, but it does occur. And I think it brings up another topic. I mean, why are physician assistants, nurse practitioners being used so much? I mean, in the last two decades, the use of nurse practitioners and PAs, especially in semi-autonomous or autonomous roles, has increased tremendously because it’s allowed physicians especially to expand their practices and go to cover multiple offices. But with that goes questions about billing. So maybe you could talk about billing issues, a physician assistant/nurse practitioner versus a physician. I think it’s important that people understand the risks involved with that.

Debra Shelby:
Great, great topic. I’m going to probably take a step back and before we go into that, is the documentation, prior to talking about billing. There seems to be, again, this misconception with physicians that they think that being on premise and reviewing notes allows them to basically bill out under their number. This is not correct. You saying, writing on every single note, I’ve reviewed and agree with the treatment plan, does not allow you to write, to bill out incident-to. And we’ll get into what incident-to is in a minute. So – electronic charting. Electronic charting can be a blessing and it can be a curse. And so going back to documentation, it used to be Paul, if they said if it wasn’t documented, it wasn’t done. Well, electronic charting has gotten to a point where the medical assistant is doing the charting. The provider who is tired at the end of the day, they have to look over and review the notes. So they’re going through them really quickly. And so they have these automatic dictation that’s going on that says, I’ve done this and I’ve done that and I went over the ABCDs and of melanoma. And so just because you click that button and say that you have done these things, and then the patient’s like, well, wait a minute, they never went over that with me. And so time and time again, I have reviewed some cases where it becomes a he said, she said, hey, they just clicked this button and there really wasn’t a thorough, basic skincare.

And so again, this cookie cutter documentation, you need to be cautious, you need to really review those notes. I personally have my patients on critical issues. I actually give handwritten education and the patient signs that they received this education, especially when it comes to, you know, you’ve had this full body exam and if anything changes, as we all know, melanoma or skin cancers, non-melanoma skin cancers can really ramp up within four to five weeks. And then the patient is saying, oh, it was there prior, you missed it on my exam, whatever the case may be. I’ve had a couple of cases that this has happened. So we need to go back to patient-centered care. And what does that mean? My patients are told that you are responsible for your care. It’s a patient-provider relationship, but ultimately it’s your responsibility to make sure – you didn’t get your medications, you need to call us. You have something that changed in between your visits, you need to call us. You need to let us know if anything has happened with side effects. How many times have you had a patient, Paul, that you find out later, that they were having side effects of the medication and the patient never called you. And that can be, again, used against you. You must write, again, back in the day, we used to, and I still write this today, if you get a temperature over…if you develop a fever, chills, if you are having any change in your situation, you need to go to the emergency room, urgent care if it’s after hours, if it’s a true emergency. Have you seen cases like this where in malpractice that electronic charting has actually been used against the provider?

Paul Rose:
I can’t say that in my cases that I’ve reviewed that there’s been an issue with electronic medical records. I haven’t had them. But I certainly can see where it’s going to happen, and I certainly can see where it already has happened. I would also say that when a patient gets their EOB, their explanation of benefits, and they see that they’ve been charged or Medicare particularly has been charged for something and the patient says, well I never had that done – now you run a different risk, which is the risk of the patient complaining to Medicare or Medicaid or whomever and brings up that whole issue which you and I talked about recently about whistleblowers. Sometimes it can be somebody in your own office So if you’re not billing correctly, if you’re not billing correctly with physician assistants, nurse practitioners, you run some substantial risks in terms of fraud, which I know that you’ve reviewed cases like that. But from my perspective, I can see where electronic medical records is a big problem. I personally have not had a case where it was the electronic medical record. There’s usually a lot more to it than that, that’s at issue.

Debra Shelby:
Yes, so going back to when we talk about the informed consent electronic charting and having the patient sign and that sort of documentation, we really need to be careful that you standardize the way that you approach your informed consent, who’s giving the informed consent, and do it the same way each and every time. And so even though the patient signs the paper really quick, you are responsible for basically going over it, giving them the reason why you’re doing the procedure, risks and benefits of the procedure, and making sure that any alternative treatments that are out there are given to the patient.

Paul Rose:
Even alternative treatments with another physician. You know, there may be another specialty that the physician cannot handle themselves where they should have referred the patient out for another type of treatment. Let’s say the physician doesn’t do radiation therapy in dermatology. The patient needs to be aware of the opportunity to have radiation therapy as opposed to typical surgeries, for instance. The other thing about electronic medical records that I’ve noticed is that they don’t really allow you to edit them very easily, to add in customized thoughts. So because you’re seeing a lot of the charts at the end of the day, you’re disinclined to have to go through all the editing that would need to be done and the language that needs to be changed within an electronic medical record. It can be really frustrating to try to be more specific. You want to call the area one location, but the electronic medical record has already decided it’s a completely different location than what you’re actually trying to say. It’s decided on an anatomical nomenclature that is not as specific as you want it to be. Whereas in the old days, again, I’m an old physician, I used to draw in the places where the lesions were. I could actually put the measurements from one point to another and triangulate them so they would be easy to find the next time and take photographs as well. Sometimes the electronic medical record doesn’t allow you to do that, and you may recall that with paper records you could easily go back through the chart, especially in a single specialty, you could easily go back through the chart and see what you’ve been treating whereas with an electronic medical record you may have difficulty really looking at what you did two months ago or three months ago or a year ago. It’s just not all there in the way that you’d like to see it.

Debra Shelby:
I agree. I can’t agree more than that. It’s just we come from, remember the days of Polaroid cameras, Paul, we used to take Polaroids of patients and, and those were the days I say, now we have the iPads, which I use. And so I actually do all my triangulation on the iPad and print out on paper and put it in the chart because I want to do my measurements. But you’re 100% right. The medical record calls it one thing, and on the electronic record, and then on your pathology, you’re actually called – scalp lesions are notorious for this. Scalp lesions, you have the set, the pathology says vertex, the other one says parietal, and now are you dealing with two separate lesions? Is it the same lesion? What is it? That’s why photography should be paramount and when you are documenting your biopsies, you can’t take enough photographs, but I have really looked at numerous cases where the electronic record and locations have been skewed because, again, are we looking at when we’re going back and we’re looking at our charts at eight o’clock at night Are we going back and saying hey, did we label it this, was it really that? No, most people are just clicking and saying, putting through their note, this looks pretty good, I’m going to send my note off. And so I think leaving really the best topic for the end of this discussion, and we will have many, many other episodes that we’ll go into deeper and deeper into things as far as things like documentation. But I really think this most important topic of what we talked about incident-to and the actual, the advanced practice provider’s responsibility for knowing what, how you are being billed out. You cannot plead ignorance in your defense saying that, well, it was the clinical practice people who sent out my billing. No, every single provider must apply for their own Medicaid and Medicare number. And we need to be responsible that when we are seeing those patients that if we are not billing out under incident-to, that it’s going under our number. And so what is incident-to? Incident-to is very clear. The physician must be direct supervision on the premise, then they must see the patient, do the physical exam, come up with a treatment plan for whatever diagnosis. So if it’s acne, psoriasis, after that visit, then the nurse practitioner or PA can see that patient for those specific diagnoses that were addressed with that physician.

If the patient comes in with a new diagnosis, then they must be billed out under the advanced provider, their number, not the physician. Or just tell the patient, I will see you for the acne or psoriasis. You’ll have to see doctor so-and-so for that prior to me seeing you. If you want to bill out incident-to. You know, you might as well just bring out your checkbook. If you’re in a medical malpractice situation and you are billing under your number and you just say, I reviewed notes, that can be a problem. And again, everything comes to light when you’re in litigation, you can’t hide, there’s no hiding. Everything billing will be brought out. And so if you do go to jury trial, what do you think the jury is going to say that you’re billing out under the doctor’s number and the doctor never physically saw that patient? Again, this is a popularity contest. When I go and I try to coach people, the jury has to like you. You can be the smartest person in the room but if the jury’s not going to like you, or if things are brought up in that deposition or in that courtroom, that they’re going to say, hey, that doesn’t seem right. Why did they do that? That doesn’t seem that the physician ever saw the patient yet they’re billing out under their number. How do you think that’s going to influence their decision? So again, it’s not worth it. And whistleblowers do get a percentage. So as a whistleblower, it’s federal government, you make the complaint, you don’t even have to be involved in the actual case. I’ve known physicians who have purposely gone after other physicians, just either A, out of revenge for some weird reason, or they want to collect the whistleblower fee, which can be up to 20%. Now, if you have advanced providers that are making on the average of anywhere to $6-800,000 and you’re billing out under that number for years, how much do you think we’re talking about in the upwards of $20 million? So that’s not bad money, right, Paul? You know, for a day’s work, go ahead and do a whistleblower act and you’re getting like $2 million for, you know, $4 million for blowing a whistle on a colleague because you have evidence that they’re fraudulently billing out under the number. What do you think?

Paul Rose:
I think unfortunately that’s the situation. And all the camaraderie that comes with going to medical school with someone goes out the window, when it turns out to be related to questions about monetary issues.

Debra Shelby:
Yeah, we know what that does, right? And so, well, we know about five cases in Florida alone that that’s happened.

Paul Rose:
Money does strange things to people. Yeah, we’ve seen some pretty, pretty wild cases in Florida.

Signe Monson:
I want to thank you guys so much for that valuable insight. I mean, just sitting here listening, I know you guys joking about how long you’ve been in practice, but, a plethora of information. You guys could go on and on, it seems like. I know that our listeners I am sure have got some great takeaways, but I was wondering if either of you wanted to offer up what you think is one or more of the most important takeaways to leave or any other parting words of wisdom to leave our listeners with, like, if you remember one thing from this podcast – what would it be?

Paul Rose:
You know, I think from my perspective, it’s for the physician to pay attention to the state laws that affect his or her practice in regard to the use of paraprofessionals and what’s expected of the physician in terms of having some type of collaborative agreement with the paraprofessional.

Signe Monson:
Well, sounds like words to live by. Thank you guys so much again. And thank you listeners for joining us on Core Matters in Healthcare. We hope you enjoyed this episode, and we invite you to join us again for upcoming episodes from this series, Lessons from Litigation. And also other episodes that we’re offering, which offer perspectives on what’s happening in healthcare and how it impacts providers. So remember, please follow CoreMedSource. Please like us anytime you see us on social media. And if you haven’t yet, please visit us on coremedsource.com. See you next time!