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Making the most out of PAs and NPs


Nurse practitioners and PAs are crucial parts of any healthcare system, but determining how they can best contribute to the success of your practice or organization takes research and planning.

Nurse practitioners and PAs are crucial parts of any healthcare system, but determining how they can best contribute to the success of your practice or organization takes research and planning. Advanced practice providers (APPs) combined with physicians can help lower costs, improve patient outcomes, and deliver quality and timely patient care.

State regulations

There are a variety of models for APP practice around the country. Regardless of which model you are using it is important to ensure you are using the fullest extent the law allows. Some states allow APPs full autonomy, but some practices are tempted to still have a physician see every patient so they can receive full re-imbursement. Utilizing APPs may let those practices bring in more patients allowing physicians to focus on higher acuity patients. Providers may be getting a reduced rate, but it could increase the volume they’re seeing for their practice.

It is also important to periodically check the state regulations for any changes, especially if those changes expand what APPs can do.

Utilization and billing

How your APPs provide care and interact with patients will vary depending on your facility’s goals and state regulations. In some facilities, physicians and APPs share a patient panel, while others have APPs manage their own patients.

Some specialties lend themselves better to APPs working independently. For example, a family nurse practitioner may be able to easily take on their own case load without physician oversight. On the other hand, surgery specialties often require the oversight of a physician but can be utilized for pre-op and post-op rounding, and even act as first assistant during surgeries.

Some facilities have patients first see a physician for diagnosis then schedule follow up visits with an APP. In some cases, this allows the facility to still bill under the original provider and get 100% of the compensation in ‘incident-to’ billing.

Facilities where APPs operate independently may not be able to bill as much for these visits, but it doesn’t necessarily decrease profit margins. Paying your APPs commensurate to the reimbursement rate can help you balance your profit margins.

Determine roles

“There’s a lot of gray area in work for APPs,” says Ronna Smith, manager of APP clinical education at Seattle Children’s Hospital. “The first thing we do as a leadership team when we’re analyzing whether or not a team should add an APP is get to the nitty gritty of ‘what is the work?’ What do they envision the APP doing? Is it billable? Does it require medical decision making? Is it provider-level work?”

It’s important to include APPs in making these types of decisions. They have great perspective and can bring ideas for how to set up your model.

“It’s important for physicians to understand the strengths and weaknesses that APPs come to the table with,” Smith says. “APPs can rise to any challenge you put in front of them. But to make it as successful as possible, you need intentional training and a good care model plan.”

Improve patient care

After incorporating APPs into their organization, Smith says the change at Seattle Children’s Hospital has increased provider flexibility and allowed them to provide better care and education to families.

“Our model is very collaborative where nurse practitioners and physicians work together within various teams,” says Smith. “If a child is on the schedule to see if they need a tonsillectomy, the initial work is done by a nurse practitioner. If the NP feels that child should move forward with a surgical plan, they pull in a surgeon who is working with them in the same clinic. The surgeon would verify the exam findings and the plan, answer any questions the family might have, and then that child would go on that surgeon’s schedule. So, in that same visit, the family would see an NP who would do the bulk of the work, and the physician can spend more time in the operating room.”

During the 2020 pandemic, the model has also helped the hospital be flexible and adaptable. “We have an APP fellowship, and those learners are assigned to multiple areas of the hospital during their training year,” says Smith. “They’re credentialed to be in multiple places, they’re used to changing assignments frequently. We had a whole contingency staffing model in place, and the adaptability of our past and present APP fellows on our staff is what made that model possible.”

Whether you run a hospital system or a small practice, including APPs in your healthcare staffing model can help you reduce cost and generate revenue while still providing high quality care to patients.

About the Author

Lisa Grabl is president of CompHealth, the nation’s largest provider of locum tenens physicians and founder of the traveling physician industry. She joined CompHealth in 2001 as a sales consultant and served in a variety of management roles prior to being named president in 2017. Lisa is passionate about building lasting relationships and helping her team members reach their highest potential.

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