For the past year, Adriel Perez has been fighting with insurance companies. Between phone calls, emails, and paperwork, he's devoted hours to it — time he could have spent with patients in his Florida primary care practice.
But Perez, a nurse practitioner (NP) who also specializes in diabetes and chronic endocrine disorders, hasn't fought extensive red tape to get a treatment approved or appeal a denied claim. Instead, he struggles to get insurers to even recognize him as a provider in their networks. Without being able to accept more insurance plans, Perez mostly treats self-pay patients, which limits his practice's marketability and growth.
"Some payers give nurse practitioners a hard time and say they don't directly credential with us 'mid-levels,' to use their term," said Perez. "It's crazy because Florida has the autonomous practice law now and one of the worst primary care shortages in the US."
In March 2020, Florida legislators passed HB 607, allowing some NPs to practice independently without a collaborative agreement, including those like Perez, who work in primary care and have already completed 3000 clinical hours supervised by a physician.
When Perez opened his practice, he expected credentialing to take about 3 months. But as the process drags on, he told Medscape Medical News that he's considering entering into a collaborative agreement with a physician — a potentially costly and unnecessary step, per the state's law — to see whether it will expedite payer approval.
Perez's dilemma highlights the catch-22 that NPs sometimes experience when trying to practice at the top of their scope. Despite the fast-growing profession often being touted as a solution to the nation's worsening primary care shortage and more states passing autonomous practice laws, NPs say they face frustrating hurdles and high costs that restrict their reach.
The Collaboration Conundrum
About two dozen states permit full practice authority for NPs, reports the American Association of Nurse Practitioners, which the organization notes can improve care access for underserved and rural communities and reduce healthcare costs. In these states, NPs do not have to establish collaborative contracts with physicians and are not subject to oversight by the state medical board.
In other states, NPs have reduced and restricted practice capacities and must maintain a collaborative agreement for the entirety of their careers.
Physician assistants (PAs) are usually held to similar standards that require a formal physician relationship, says Angela Shuman, vice president of state advocacy and outreach at the American Academy of Physician Associates. However, she told Medscape that six states now offer PAs the equivalent of full practice authority: Arizona, Iowa, Montana, North Dakota, Utah, and Wyoming.
Entering a collaborative agreement is easier for some than others. NPs pursuing employment with a medical group or health system are typically paired with a physician on staff. However, connecting with a physician becomes much more difficult for those seeking to open their own practices, says Graig Straus, DNP, APRN, CEN, president of Rockland Urgent Care in West Haverstraw, New York.
He told Medscape that NPs opening a private practice in a full practice authority state like New York don't need a collaborative agreement once they've accumulated 3600 supervised hours. Before then, they need one.
Straus, a clinical instructor for NPs, says finding a willing doctor is increasingly tough amid clashes over scope creep and liability. Physicians may be hesitant because they are often named alongside NPs and PAs in medical malpractice cases and worry about being sanctioned by state licensure boards.
Still, Straus says that physicians aren't usually held liable.
"NPs are independent providers and have their own licensure. The doctor doesn't double-check their work or co-sign their charts," he said, adding that the collaborating physician's role is retrospective. They periodically review an NP's cases, ensure they practice to the standard of care, and are available to answer questions, says Straus.
The Match, but for NPs
Ideally, NPs should collaborate with a physician in the same specialty, but Straus says they may need to get creative and pull from the network they grew during their nursing careers or clinical rotations.
Some eventually turn to a "matching" service. Annie DePasquale, MD, a family medicine physician, started Collaborating Docs in 2020 to connect NPs and physicians. She says options can be limited because most doctors are risk-averse and not interested in the role, and those who are willing may be out of reach financially. "They ask for large sums of money but then are not knowledgeable or reachable when needed," she said.
DePasquale told Medscape that NPs may also struggle to secure malpractice insurance, complete credentialing, and find an attorney experienced in drafting the agreements. She says that some malpractice carriers won't cover the collaborating physician or let NPs add them to their plans, and payers often require both providers to be credentialed.
This process can take 6-12 months and has an initial set-up fee of several hundred dollars, with monthly payments up to $300 per payer per provider, she says.
"It's financially burdensome for an NP to pay the physician for such a long time before being able to open up their practice and start making income," said DePasquale.
Straus owns three urgent care centers and is opening a primary care NP group after multiple physician practices closed in his area. He agrees that high operating costs are another hurdle.
Collaborating physicians charge monthly fees ranging from $300 to $1500, and some want to have their full malpractice insurance covered, but Straus says a rider policy on the NP's plan may be a better and cheaper option to cover the physician.
According to Straus, NPs and even attorneys may use incorrect provider taxonomy codes on credentialing forms, which can also lead to delays.
To alleviate the bottleneck, New York legislators are considering a bill that would allow experienced NPs to supervise newly licensed NPs. The Medical Society of the State of New York opposes the legislation, saying it would endanger "patient safety by removing physicians from the health care team."
DePasquale says that loosening restrictions in more states, such as permitting collaboration activities to be performed remotely via phone or video chat, could ease some of the current challenges NPs face and improve care access.
Steph Weber is a Midwest-based freelance journalist specializing in healthcare and law.
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