The Evolution of the Mid-Level Provider

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At the ACEP Scientific Assembly this year, I spoke to a group of physician assistants and advanced practice nurses. I gained many insights into the uniqueness of their role and their place in Emergency Medicine.  The first thing I learned was that terminology is evolving as their training and scope of practice is evolving.

At the ACEP Scientific Assembly this year, I spoke to a group of physician assistants and advanced practice nurses. I gained many insights into the uniqueness of their role and their place in Emergency Medicine.  The first thing I learned was that terminology is evolving as their training and scope of practice is evolving. I knew that many were becoming dissatisfied with the label, “Mid Level.” However, I hadn’t heard any titles suggested to replace it. Well, that has changed. The term, Advanced Practice Provider was mentioned to me, as both PAs and Nurse Practitioners have advanced degrees. This makes sense to me. So, unless this takes a different direction, I think we should adopt this term.


In my discussions with APPs and physicians across the country, several interesting nuances and potential pitfalls have become glaring obvious to me. Looking at our workforce in medicine in general and Emergency Medicine, unlikely would be an optimistic statement, with respect our ability to supply every U.S. emergency department with residency trained, board-certified/eligible emergency physicians. As a matter of fact, the AMA has reported a projected physician shortage of 200,000 by the year 2020 and 400,000 by 2030. As the practice of APPs evolves, it is natural that they take their place in our health care system. If they aren’t already, they will soon be regarded as a critical component of our emergency care delivery system.

The question isn’t if, it’s how. There are many questions to consider when discussing how APPs fit into the equation. Needless to say, physicians, in particular emergency physicians, should be guiding this process to ensure construction of a system that best meets our patient’s needs.

Before you sign off on another stack of “supervised” APP charts, I want to address a concern I have. Although APPs are being incorporated into our staffing models at an astronomical rate, our approach to supervision is way behind. Best practices should be defined. However, in the interim, we have to make certain that how we supervise is both safe and compliant.


Supervision from an operational perspective is much different than from a coding and billing perspective. Supervision in the operational sense implies some sort of direct impact on patient care; at least to me it does. However, supervisory agreements, that vary state to state, and often mirror that of CMS, don’t necessarily require the physician to be on site, just available. Thus, many “supervised” cases do not result in real-time input or any direct physician interaction with the patient. All physician assistants must function with a supervisory agreement with a physician. However, this is not so for advanced practice nurses (APNs). Initially, the requirement was for a collaborative agreement, which is a bit less restrictive than a PA supervisory agreement. Currently, many states have even removed the collaborative agreement requirement for APNs. Thus, many APNs function autonomously. However, I would suspect this is much less likely in Emergency Medicine, except for underserved areas.

With respect to coding and billing, watch out for the quick sand. It may be common knowledge that if the patient is only seen by the APP, then the visit can only be billed at 85% of the physician fees, per CMS. However, if the physician is involved, the visit can be billed at 100%. This is where I have found a great disconnect in people’s thinking. Signing a chart, although it may meet the state’s supervisory requirement, does not pass the sniff test when billing at the physician level. To bill at the physician level, this is considered a “shared service.” This is very similar to the office-based concept of incident-to billing. For a shared services claim in the ED, the physician must have face-to-face time with the patient and document their findings a supervisory note. If face-to-face time does not occur, then the visit cannot be billed at 100% of the physician fee schedule. If input is provided real-time, but no face-to-face time occurs or the chart is just signed, the visit can only be billed at the 85% level. I suspect that many EDs stretch this rule to the point of noncompliance. Some third party payers may not follow CMS’s lead on this, offering a more liberal approach.

However, I’m not certain all physicians are mindful of the differences of various third party payers, particularly while working a shift. It seems reasonable to select the more restrictive approach that will be compliant for all visits, as opposed to a more permissive approach that may lead to trouble later.

A final note is regarding supervision and risk management. Even if the supervisory requirements have been met and the coding and billing is compliant, what exposure does the physician have while supervising an APP? In the Emergency Department, our close proximity to the patient increases or decreases our exposure, depending on how you look at it. If your brand of supervision is signing the charts but not providing any face-to-face time or even any real time advice or interaction with the APP, you may be at greater risk if a bad outcome occurs. Remember, the jury won’t likely care that you met the statutory requirements for supervision but didn’t even see the patient. However, if you saw the patient, a defense can be strengthened by that action and the direct involvement you had in the case. You’ve got to ask yourself, “Which position would I rather be in if a lawsuit is filed?”


There is certainly a balancing act between operational and financial efficiency, aided by APPs and quality of care and risk management. The right balance is likely a bit different for every group and/or department. However, the critical issue is to identify the benefits and risks of your approach and feel comfortable with how you’ve incorporated APPs into your practice.

Dr. Kevin Klauer is the editor-in-chief of Emergency Physicians Monthly, the CMO of Emergency Medicine Physicians, and the vice speaker of the ACEP Council.

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  1. What a great read on a tough subject. Unfortunately, I have to respectfully disagree with DR. Klauer. While there is a physician shortage now and more so in the future, the PA/NP’s are not being utilized for this problem. For example, ever try finding an EM job in southern California, good luck, but yet there is an abundant workforce of EM PA/NP’s. No, the PA/NP’s is not assisting with the so called physician shortage. The title of Advanced Practice Provider is deceiving to the patient. If they are advanced, then what are the board certified EM physicians, super advanced practice providers. And if seeing as many of their patients as possible helps decrease litigation, then what are we doing with them in the department, why not use a retired family or emergency medicine physician, who want a few extra hours. Everyone seems hard pressed to ensure we have board certified EM physicians in the department, but turn the other way when it comes to the PA/NP’s. The PA/NP’s role in the emergency department is to be part of the team, to help with flow of the department, and save the group money. It is time to call a spade a spade.

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