Newly enacted 464.0123 created an unprecedented expansion of the scope of practice for both APRNs and nurse midwives. It allows for qualified APRNs (there is specific criteria) to practice independent of a supervising physician in the following areas of medicine–primary care, family medicine, general pediatrics, and general internal medicine.
Even more, assuming they meet the membership criteria for admission to a healthcare facility medical staff, they may admit patients, manage patient care, and discharge patients. One of the only preserved connections with a physician established by the law is if the APRN practices at a healthcare facility, a transfer agreement including a physician is required. Additionally, the new law establishes a Council On Advanced Practice Registered Nurse Autonomous Practice, two members of which are appointed by the Board of Medicine and an additional two appointed by the Board of Osteopathic Medicine.
While a “game changer” in Florida, the new law also extends to APRNs many of the same restrictions and regulations applicable to physicians for many years, including state self-referral restrictions (the “Florida Patient Self-Referral Act of 1992”), adverse incident reporting, fee splitting prohibitions and professional liability insurance requirements, none of which were directly applicable to APRNs before the new law.
The law distinguishes between APRNs that engage in autonomous practice and those that do not, pinning very particular clinical requirements and responsibilities to those who elect to practice autonomously. They are not all bound by the specific provisions applicable to autonomously practicing APRNs. Finally, the new law is clear that neither commercial insurance, self-insurance nor HMOs may require a patient to treat with an autonomously practicing APRN.
The new law will require APRNs who desire to practice autonomously to come up to speed on things like:
- The Florida Patient Self-Referral Act of 1992, which (a) prohibits them from owning certain healthcare services (“designated health services” or “DHS”) and referring to them, and (b) imposes supervision requirements on them for the provision of allowed DHS;
- Professional liability insurance. They will need to understand about concepts like “claims made vs. occurrence coverage and tail insurance;
- Medicare regulations which, among other things, require (1) patients who will receive non-covered services to first sign an ABN form; and (2) federal supervision requirements;
- Corporate law, so they make the best choice in terms of legal entity through which to practice (e.g. LLC vs. PA and s corp election with the IRS);
- Restrictive covenant law, which will help them understand how to best protect their business via non competes, non-solicits and confidentiality provisions;
- The state Health Care Clinic License Act, in the event they want to open a practice with a non-physician/non-APRN owner; and
- All issues pertaining to in network and out of network provider arrangements.
In addition, there are serious business pressures that have to be carefully navigated to ensure success. This is especially the case because the specialties where autonomous practice is open (GP, FP, PCP and internal medicine) happen to involve lower reimbursement by payers and high staffing requirements. From a business perspective, these are not “easy” practices. Issues like HR, billing and collecting, practice administration and regulation are especially challenging and will likely be even more challenging to APRNs who likely will not receive the same level of reimbursement from payers that physicians do. In short, it’s aint easy! Especially when one considers that the primary adaptation in these service areas is to combine and be part of a larger practice group, if only to better bear the overhead expenses. The trend here is NOT more and smaller practices.
The expanded scope of practice for APRNs will likely create tremendous opportunities for those who prepared, well-educated and advised BEFORE they move forward. While not a “one size fits all” business, there are a large handful of complex issues that need to be locked down before proceeding.