October 24, 2025 • 39 mins
The growth of advanced practice providers (APPs) continues to transform the provider landscape. Joe Aguilar, Managing Partner, HMS Valuation Partners, Alaina Crislip, Member, Jackson Kelly PLLC, and Emily Grey, Partner, Breazeale Sachse & Wilson LLP, share their observations about how APPs are evolving, with a focus on issues related to billing and innovation. Joe, Alaina, and Emily spoke about this topic on a recent AHLA webinar. Sponsored by HMS Valuation Partners.
Watch this episode: https://www.youtube.com/watch?v=Tawbejwnc-g
Learn more about HMS Valuation Partners: https://hmsvalue.com/
Learn more about the AHLA webinar, “The Future of Providing Care with Advanced Practice Providers - New Market Models and Challenges”: https://educate.americanhealthlaw.org/local/catalog/view/product.php?productid=1651
Essential Legal Updates, Now in Audio
AHLA's popular Health Law Daily email newsletter is now a daily podcast, exclusively for AHLA Premium members. Get all your health law news from the major media outlets on this podcast! To subscribe and add this private podcast feed to your podcast app, go to americanhealthlaw.org/dailypodcast.
Stay At the Forefront of Health Legal Education
Learn more about AHLA and the educational resources available to the health law community at https://www.americanhealthlaw.org/.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_01 (00:04):
This episode of AHLA Speaking of Health Law is
sponsored by HMS ValuationPartners.
For more information, visitHMSvalue.com.
SPEAKER_00 (00:17):
Welcome everyone to this episode of AHLA's Speaking
of Health Law podcast.
I am very excited today for thisepisode on all things APP or
advanced practice providers withmy colleagues Alina Chrislip and
Emily Gray.
We had so much fun with thistopic just last month on a
(00:39):
webinar that we thought we'dtake the show on the road and
have even further conversationtoday.
With that, my name is JoeAguilar.
I am the managing partner withHMS Valuation Partners and have
focused my 30 plus years onphysician and APP compensation
along with fair market value andcommercial reasonless work.
(01:02):
With that, I'll pass it to mycolleagues to introduce
themselves.
And I guess we'll start withElena.
SPEAKER_02 (01:08):
Thanks, Joe.
Elena Chrislip.
I'm a healthcare regulatorycompliance lawyer, sort of the
general practitioner ofhealthcare law here in uh
Charleston, West Virginia atJackson Kelly PLLC.
SPEAKER_04 (01:23):
And I am Emily Gray, and like Elena, I have kind of a
broad regulatory practice.
I'm located in Baton Rouge,Louisiana, where I am a partner
at Brazil, Saxe and Wilson, andI'm on the firm's management
committee.
And in my 25 years, I'verepresented a variety of
healthcare providers of allshapes and sizes.
SPEAKER_00 (01:46):
All right.
Well, I think as I think backwhen we first started connecting
on this, because we actuallytalked on or presented, I should
say, in February with theadvising providers conference.
What struck me to on this topicwas just the continued use of
APPs.
(02:06):
As a nurse practitioner myself,which I started 20 plus years
ago, it was primarily just a fewspecialties, and now they they
seem to be integrated into notonly the specialties, but even
the subspecialties.
(02:29):
MGMA just recently uh put out apoll and which uh asked medical
groups what percentage of the umof them were thinking about
adding new APP positions, and itwas over 65 percent, um, which I
I I find remarkable justthinking back you know 20 plus
(02:50):
years ago as a student.
But um that obviously has led toum the I guess the legal
profession and compliance folksto figure out ways to do it
right um and avoid um any anypitfalls.
I guess um I'll I'll leave it uhgive it up to you, Elena or or
Elena, sorry, or um or Emily uhas to um you know how how do you
(03:16):
see that growth impacting umwhat you're seeing on a
day-to-day basis with APPs andyour clients.
SPEAKER_04 (03:24):
I'll jump in real quickly.
One of the things I wasthinking, Joe, as you were
speaking, is that part of theevolution we're seeing is kind
of the evolution in our overallpopulation, right?
As we have, you know, kind ofour a number of physicians, kind
of a silver tsunami aging out,um, looking at using our
resources wisely and extendingphysicians as best we can with
(03:48):
APPs, I think makes a realdifference in the healthcare
space and the delivery of care.
And I think that's perhaps partof why we're seeing, you know,
the the increase in the numbers,um, and just that it works.
SPEAKER_02 (04:01):
I I would agree with that.
I I also don't know, you know,because of I still feel like
things are still backed upbecause of the the COVID, the
public health emergency.
We still have a lot of backlogswith physicians, and you know,
if you can't multiply yourself,how how do you extend yourself,
right?
And the use of APPs both inhospital settings and and
outpatient settings, I think ishelping, you know, to to address
(04:23):
and make sure that physicians umare meeting and and seeing all
of their patients to the extentthat they can.
SPEAKER_04 (04:31):
And I think patients are more comfortable with APPs
now than they were maybe 10 or20 years ago.
Um you know, I think about myparents who were more like, I
want to see the doctor, um, asopposed to folks who are really
happy with the level of accessand the level of care that's
provided with APPs more now.
SPEAKER_00 (04:52):
I mean, I think that that certainly resonates with me
because um 20, 22, 23 years ago,um the concept of the nurse
practitioner even mentioningthat I was going back to school
uh to Hopkins to seek thisdegree uh just was um not really
understood by the generalpublic.
And now you're seeing nursepractitioners in the
(05:12):
commercials, uh, you're seeingum shoot even hitting the big
time with Netflix, uh, what'sthat series, Virgin River, uh,
with their with their lead uhlead um heroine uh as a nurse
practitioner.
But um but no, I I I agree.
What's what's what's beeninteresting in this is I I've
been able to get the opportunityto talk with provider
(05:34):
compensation specialists acrossthe country, and they brought
together a panel of APPs thatare actually certified in
rheumatology, in neurology, andall these sub-specializations,
and they're being certified inthat manner because um
organizations are put puttingtogether fellowships um for APPs
as well.
So I it's it it's just changedthe landscape tremendously.
SPEAKER_02 (05:58):
I I don't think we should lose sight either, Joe,
and and you probably know thisbetter than anybody that in in a
lot of states, a majority ofstates, nurse practitioners can
hang up their own shingle aswell.
And so, you know, to the extentwe start getting into some of
these billing rules, nursepractitioners based on state law
can also delegate, right, andand be functioning uh in in that
role where they're delegating toothers.
(06:19):
So I I think that's kind of animportant point as well, that
they can themselves hold uptheir own shingle um depending
on the state law involved.
SPEAKER_04 (06:27):
That is so true, Elena.
Um, and in you know, ourpresentations, I was kind of
focused on the state law.
And even in a matter of sixmonths, there were changes
where, you know, Arkansas, forexample, I had to go back and
make updates because theyallowed autonomous practice for
their NPs and just changed thelaw very quickly.
And I think that's a trend thatwe're seeing in the states.
(06:49):
I think, you know, with thisincrease in comfort with the
APPs, we're seeing states givethem, you know, kind of broader
authority.
SPEAKER_02 (06:58):
And I think, Emily, too, and Joe, maybe you can
speak to this.
I mean, there is a workforceshortage, right, from the
healthcare perspectivegenerally, and that might also
be, you know, uh one of theimpetuses for for states wanting
these folks to have moreautonomous ability to operate on
their own to help address theworkforce shortage.
SPEAKER_00 (07:18):
I completely agree.
I I I I think um, and this isprobably a topic for another
podcast, but even the idea oftraining APPs um and how are
they trained, um, what type ofum clinical experience do they
have while they're in school?
Is there a role for even aresidency program for APPs in
(07:42):
the future with so manyresidency spots going unmatched,
as well as you know, communitiesnot necessarily being fully
serviced?
So I I think there's a lot thatI uh you know, what is our topic
called?
Charting the future.
I I I think there's a lot ofpathways for the future of APP
practice, there's there's nodoubt.
(08:03):
And I also think it makes sensejust from the models uh you know
standpoint, um, you know, whenyou think about primary care uh
and and your first newappointment is three weeks out,
uh it that just doesn't makesense that you don't have
advanced practice providersbeing able to see that patient
because they can handle the vastmajority of primary care within
(08:24):
the scope.
Um and then when you think aboutthe um subspecialties like you
know neurology or endocrinology,there's a lot of ways that they
can extend um, or even thesurgical practices where they're
dealing with follow-up or orpre-surgery assessments.
Um there's lots of ways thatthey can um really facilitate
(08:45):
the care of more more patientsas as as um we mentioned.
But I I guess and this has beenan issue for us uh for me ever
since I was uh a new NP, is allthe billing nuances um that
arise with this.
Um I mean what do you all see assome of the challenges there to
(09:08):
keep you know health systems astheir employers or APPs in
general um on the straight andnarrow with regards to billing?
SPEAKER_02 (09:16):
Yeah, so I mean that's a that's a great point.
I mean, short of direct billing,right?
And and making sure that youknow you're meeting medical
necessity and billing under thepractitioner, either the
physician or or other APPs ownMPI number, you're there are you
know incident two and outpatientsettings, um, and then there's
split shared and institutionalsettings.
And I think that you know it'scritical compliance for for
(09:39):
meeting these um billing rulesis is important for for entities
and making sure that you havethe appropriate documentation,
reflecting that you're meetingall of the specific rules
involved with with each of thetypes of billing rules.
SPEAKER_00 (09:56):
Yeah, no, I mean I I think do do y'all find um are
y'all getting a lot of questionson that subject as as health
systems dive into more and moreuse of APPs?
SPEAKER_04 (10:07):
I'm not seeing so much questions with the billing
requirements as I am, you know,and I'm just thinking this week
we saw some questions um for aprovider who has, you know, the
physician was out on vacationand then saw an unusual number
of patients, you know, using hisNPs.
And I think there is somescrutiny there, um, and you have
(10:30):
to be real careful about thebilling um and and how you're
handling it, particularly withyou know, if you're trying to do
a high volume of patients uhunder a single supervision
supervising physician.
SPEAKER_00 (10:45):
Yeah, that I mean I that's an interesting comment
because we've seen um a coupleof situations where, and again,
this is state by state umdriven, but where a single
physician may be supervisingthree or upwards of ten or more
APPs, and you know, what'swhat's okay, what's not okay,
(11:05):
even beyond what the state regssay in the moment.
SPEAKER_02 (11:08):
Um and I would argue to show that you're you're
you're when you're billing,you're saying you're meeting all
the billing requirements and allrequirements under state law.
So if you're supervising moreAPPs than maybe you should be, I
think there's an open questionas to whether or not you've been
actually meeting all therequirements to bill, um,
depending on how you bill thoseservices.
So um I don't know, Emily.
(11:29):
I know that you in yourpresentation you gave a lot of
like the specifics from state tostate as to how many, you know,
APPs a physician could couldoversee.
So I don't know if you have anyother thoughts on that.
Yes, y'all lined that up for meperfectly.
SPEAKER_04 (11:44):
Um thank you.
That's my cue.
Um, really, one of the thingsthat's that's critical when
you're setting these up ismaking sure that you're familiar
with what the state lawrequires.
Um, there are tremendousvariances in supervision ratios
state by state.
Um, some states like Arizona andColorado don't require any
(12:06):
physician supervision.
Um other states have aggregatelimits.
So, you know, in looking at someof these, and I gave a laundry
list of states and requirementsin the presentation.
Um, but they're, you know, ifyou've seen one state, you've
kind of seen one state.
South Carolina has a limit ofsix in the aggregate, NPs are
(12:27):
PAs.
Alabama has a limit forphysicians that can only
supervise up to 360 hours perweek, which are nine FTEs of NPs
and PAs.
Some have limits on PAs, but notNPs, like in Delaware,
physicians can collaborate withfour PAs and no limit on NPs.
(12:47):
Louisiana, my state, uh aphysician, there's no limit on
NPs.
That limit was removed, gosh,probably 10 years ago.
But there's a limit of eightPAs.
Um, and then some states requireyou to have backup physicians in
addition to that one supervisingphysician.
So there is a lot of variance.
SPEAKER_00 (13:06):
Yeah, and so thinking about supervision, so
at when I practiced, um I I haduh the pleasure of actually
having a separate clinic where Iwas connected to my um
collaborating physiciantelephonically.
So if there was a need, they youknow, I I could call them.
Um but I know that you know withincident two and other and other
(13:28):
type of billing rules, there'skind of certain restrictions or
regulatory requirements to meetthose rules.
I think uh Elena, you spoke onsome of those, um, even specific
to like location of thephysician.
SPEAKER_02 (13:42):
Yeah.
So for for incident tworequirements, the um incident
two billing requirements orbilling rule, you know, the
physician has to uh providedirect supervision to the um the
provider that they are are umbilling the service incident to.
I did want to clarify that itcan't, you know, it's a patient
if you're if it's incident tothe physician, right?
(14:03):
It's a patient that's alreadycome in that the physician seen
developed a treatment plan for,and the the APP is is reviewing
the plan of care and you know,just evaluating the patient
consistent with what uh thephysician has already developed.
And so as far as the directsupervision, they have to be
present in the office suite andimmediately available to furnish
(14:24):
assistance.
And so depending on the Macinvolved, if there's any
questions, you know, you canhave a discussion with your Mac,
but it's also sort of a commonsense type approach.
Um, if you have a suite on thefirst floor and you also have a
suite on the third floor, youknow, and your physician's on
the third floor and your APP'son the first floor, that's
probably not really directsupervision.
Um, I think there's even aquestion, depending on the Mac,
(14:46):
if you have an L-shaped suiteand the physicians at one end
and the APP's at the other, andyou can't really, they can't
hear you, right?
Unless you have some sort oftelecommunication or um intercom
system in the in the suite, thatthere might be a question as to
whether or not that is actuallydirect supervision.
And so they have to be availablefor questions.
(15:07):
Short bio breaks are okay, but Imean, if they're otherwise
involved involved in in treatinganother patient or in the middle
of a procedure and wouldn't beavailable, I think there's a
question of whether or notthey're meeting direct
supervision.
And and kind of going back tothe compliance uh part you
mentioned earlier, Joe, is Ithink that the the doctor should
document, right, in the recordwho was the, you know, or the
(15:28):
APP, who was the physician or orthe person who was providing um
the direct supervision for theincident two service to be
billed.
SPEAKER_04 (15:37):
The devil really is in the details.
I mean, it seems so persnicketyfor the health lawyers to say,
okay, it matters if yourbuilding is L-shaped or if
you're on the second floor orthe first floor with your NP.
It's um uh remarkable how howdetailed and careful they have
to be.
And if you multiply a problem bya year or two years, um, it
(15:59):
starts adding up to be a reallyexpensive problem potentially.
SPEAKER_00 (16:03):
I agree.
I I I I just out of curiosity, Imean, uh do y'all are y'all
seeing incident two questionsmore prevalent with your
hospital health system clientsversus your private medical
groups?
Um and the only reason I ask isbecause we're we're seeing a lot
of health systems seem to wantto move the way of direct
(16:25):
billing and not necessarilyusing the NPI number of the
APPs.
And but yet when you've gotthese medical groups that either
uh joint venture or becomeacquired, um which they still
are, it's still happening, um,you see the medical groups being
more comfortable billingincident two.
Um no doubt avoidance of the 85%reduction or 85% reimbursement
(16:47):
rate.
But just curious if if you guysare seeing any particular type
of clients for this question.
SPEAKER_02 (16:55):
To move to the to to try to uh obtain the maximum
amount of reimbursement.
Yeah, I think I think that'salways you know on on the you
know a matter of evaluation in abusiness decision, right?
Because as we we've pointed outhere and in our uh webinar,
there are compliance risksassociated if you're not meeting
the billing requirements.
(17:16):
And so especially um, you know,there can be some substantial
paybacks with with both shared,you know, split shared um
billing and incident twobilling.
And so I do, I do think to yourfirst point there, Joe, you're
seeing a lot of folks say, well,it's not worth the headache.
We know operationally we're notgonna document the requirements
to meet this if we're everaudited.
(17:38):
Um, so we're just gonna directbill, right?
To the extent that ourphysician, our nurse
practitioner, our folks candirect bill, we're gonna just
have them bill under their MPInumbers and we're willing to
take that 85% reimbursementversus the 100%, you know, the
physician fee schedule because,you know, we can sleep better at
night knowing that we don't havethese open compliance risks that
(17:59):
we need to be auditing for.
SPEAKER_00 (18:01):
Yeah, yeah.
SPEAKER_04 (18:03):
Well, and uh my experience is is similar.
And I think when I look at youknow, my practice, we get more
questions from medical groups,um, and they seem often more
willing to uh push the envelope,perhaps, uh, than some of the
health systems.
Um, and you know, they may haveless questions, or I think they
have less questions becauseprobably they're more
(18:24):
sophisticated and morerisk-averse.
SPEAKER_00 (18:27):
Yeah.
SPEAKER_04 (18:28):
Um so that that's been what I've seen.
SPEAKER_00 (18:30):
And I think that it lends itself better to certain
specialties and certain modelswhere the APPs are working.
So, like if you're primary careand trying to do incident two,
that's super hard.
I mean, Mrs.
Jones comes in for a follow-upon her diabetes, and and the
diabetes may be the initialdiagnosis that you're down
billing the incident twofollow-up care on, but she's got
(18:52):
a cold.
And now you're what are yougonna do?
Like, well, sorry, you can't seeme for the cold.
Uh, you know, and there arethere are ways you can do it,
but it requires a lot of youknow jumping through hoops.
But if I am um you know workingas the diabetes educator at in
an endocrinology practice, andmy patients are pretty you know
routinely coming in for justtheir diabetes care, I mean,
(19:15):
then it makes complete sense totry to set up a system that
allows you to bill, you know,instant two under the guise of
following at least thatcomponent of the rule.
But um, yeah, it it's it thatthat that's always been
interesting ever since I startedpracticing and how how to how to
navigate that just as an NP.
SPEAKER_02 (19:33):
Yeah, and I I was just envisioning and again, I'm
not I'm not a technologicalperson myself, but I'm thinking
that technologically there's gotto be something that I was
thinking through in an EMRsystem, for example, right?
If they're coming in for theirdiabetes and you're putting in
an additional diagnosis, in mymind that should send off bells
and whistles, right?
Or or or flag that in some wayfor your billing folks to know
(19:55):
that's a new, that they'recoming in for a new condition,
right?
And so this should not be buildincident too.
And I'm thinking in discussionswith EMR uh vendors, there's got
to be a way maybe to flag thateven internally so your your
folks on the billing side wouldknow that's gotta be billed
differently and can't be buildincident to.
SPEAKER_00 (20:13):
Yeah, agreed.
I'm not sure if that's thatthat's in place.
SPEAKER_02 (20:16):
Um I don't know, but hopefully a vendor out there
after hearing this will put itin place.
SPEAKER_00 (20:21):
I know a few of them.
I I should have thatconversation with them.
Well, I and and I'm not gonnaI'm gonna try to switch gears uh
a little bit and we'll just keepthe conversation rolling.
But um, you know, you mentioned,Elena, that NPs are able to hang
their own shingle on things.
Um, and it doesn't always haveto be in that capacity.
(20:43):
But I know, Emily, you spoke onon the webinar as well as the
the um the presentation we didat the conference up on
innovative ways of using APPs,and that you know, you're often
hit with kind of first-timequestions of, hey, can we do
this?
Um maybe you can shed a littlelight on how you approach those
(21:05):
questions.
SPEAKER_04 (21:07):
Sure.
And you know, that's really beenum fascinating and fun, and you
get to be a little creative, Iguess.
Um one of the things that I'veseen in the last few years are
some entrepreneur types um whoare looking to establish you
know virtual clinics withoutbrick and mortar, uh, which is
(21:28):
something I think, again, aswe've seen the evolution of you
know, healthcare, we see folksmuch more comfortable with
telehealth, much less need ofhaving an office.
I think that's something thatthe pandemic brought to us.
Everybody learned uh how to doZoom.
Um so what we're seeing is umyou know providers taking
(21:49):
advantage of this and lookingfor ways uh to bring care to
people in their homes, not tohave to have bricks and mortar.
Um I see folks coming in wantingto do things across state
borders in different states.
Often they come to me and say, Ihave this idea, let's start it
here, but we want to set it upin a way that we can go
(22:11):
national, right?
And so what do we look at firstwhen we do that?
Um, if we're working within-house counsel, I give them a
little bit of guidance.
And if I'm working directly withthe business people, um, you
know, I do my best to help themput on the brakes a little bit
sometimes.
Um the business folks seem to bevery eager and quick.
(22:33):
I had one group that thought,you know, as long as I get
authorized to do business in thestate, we can pretty much do
whatever we want, right?
It's like, whoa, you know, slowdown.
You know, folks need to belicensed.
We have all different kinds ofrules in every state, uh, which
I went into in in great detailin our uh in our presentations.
But I think that's somethingthat's critical when new folks
(22:54):
come in with, you know, afantastic idea, helping them
understand and navigate thedifferent pieces.
So, for example, if you're notgonna have bricks and mortar,
we're gonna have to talk aboutwho your payers are.
Are you doing a pilot project uhwith an MCO or are you gonna try
and build Medicare and Medicaid?
And if you're gonna try andenroll in Medicare, you're gonna
(23:17):
have some issues because there'san enrollment requirement that
you're operational, which meansyou have a physical location.
How are we gonna handle that?
Um, you know, I've had folkslooking at um office sharing uh
type situations and kind ofdefeats the whole purpose.
So, can you use someone's home?
How is it gonna work?
(23:37):
So, kind of getting throughthose issues first, talking
about workforce that might berequired by whatever state law
ratio there is for supervisionis important.
Um, those are kind of some keyconsiderations at first, and and
helping um our fast-movingbusiness folks to understand you
need to set it up right, or youmight have to give all the money
(23:59):
back.
Um or you know, you might getyour providers in trouble.
I've represented a couple ofdifferent providers.
One was in the state ofLouisiana where, you know, he
relied on the company who, youknow, engaged me to help the
provider.
Um, but they were missing acouple of disclosures on their
state-specific telehealth umconsent form.
(24:21):
And we got to go talk toLouisiana State Board of Medical
Examiners.
And with the companies I'vetalked to looking to do this
with the providers, myexperience has been that they
are unanimously, you know,behind their providers, don't
want anybody gettingdisciplined, don't want to hang
them out there and areprotective of the providers, but
understanding those risks to thelicenses of the physicians and
(24:45):
the nurse practitioners, andit's mostly nurse practitioners
that I see in these models, um,that's important.
Um, there are some you knowprescribing limitations.
There's one state, it's mine,uh, that has special rules on
prescribing obesity drugs.
Uh you can't do it viatelehealth.
And understanding all thoselittle nuances are are critical
(25:05):
in looking up, uh setting upthose uh virtual practices.
SPEAKER_02 (25:11):
And and that's kind of there were some public
health, you know, emergencyflexibilities that went through
that are at least some of themare going through the end of
this year.
And then the 2025 physician feeschedule adopted certain
flexibilities if you met certainrequirements.
And now I know the 2026physician fee schedule is
anticipating or at least isproposing to, you know, uh do
(25:32):
sort of all for all incident twoservices, um, more of a
broad-based um exception.
And so that's something justkind of to keep an eye on for
folks that are billing for someof these supervision
requirements, Emily.
I was tying on to your virtualaspect there, that there were
some flexibilities there from avirtual perspective that folks
should be aware of um and makesure they look into because you
(25:54):
may not have to have thatphysician for certain things
that you're billing directly inthe office, they can they can um
attend it virtually via sometype of audio video
communication.
SPEAKER_00 (26:06):
I I um along the lines of innovation, um I I just
attended a uh the annualconference for concierge
medicine today here in Atlanta.
Um and what's what's interestingabout the group or just the
concept is that I think you'restarting to see some APPs even
(26:27):
do it in certain states.
Um have have has that evercrossed y'all's desk?
Uh I mean, I because what whatwhat I'm thinking about is those
practices that not necessarilythe primary care, but the ones
that get more niche, like eitheryour a longevity practice or
your uh you know, dealing withbiodentical hormones or or
something along those lines.
Um because as I was sittingthere, I was thinking, wow, as a
(26:49):
as an APP, you know, this couldbe another means of of of um
developing a practice,developing a following with
patients, and and um potentiallyyou know aligning you know a
work-life balance or that whichproviders typically love to do,
which is spend time withpatients versus spend time with
(27:10):
all the administrative stuff.
I'm just curious if that's everhit y'all's desk by any chance.
SPEAKER_02 (27:15):
It yeah, we're seeing a lot more of that,
especially in the um, I don'tknow what you would call it, the
cosmetic realm of the case.
Where you know aesthetics, yeah,the aesthetics, you're seeing a
lot more of that.
Um, and and generally when Ihear concierge medicine, I I
think cash only, um, notparticipating in Medicare,
Medicaid.
And so um I yeah, I think you'reseeing a lot more of that.
(27:38):
And I think they're lucrativepractices.
You just have to make sure, youknow, again, you're you're
following all your compliancerequirements that you need to
meet under the state law whereyou're providing that service.
And if you, you know, if you gotto double check and make sure
you're not enrolled, you know,as participating in Medicare and
things like that, because I havehad some situations where the,
you know, physicians they'reproviding hospital services,
(28:00):
right?
And they've reassigned theirbenefits to bill and collect to
the hospital for purposes ofMedicare, but they're over here
trying to set up a practice thatdoesn't accept Medicare and it
doesn't necessarily jive.
unknown (28:12):
Yeah.
SPEAKER_04 (28:14):
Well, and anecdotally, you know, as we're
talking about kind of thingsevolving and having more of a
role for the APPs, um, you know,one of the things we were
talking about, you know, aroundthe office recently is how long
it takes to get in with people.
Joe, you were very generous atthe beginning of the
presentation saying, oh, ittakes three weeks.
SPEAKER_00 (28:34):
Yeah.
SPEAKER_04 (28:35):
You know, in my community, it takes nine months
to get in with a new TPP as anew patient.
And, you know, some of the um mycolleagues in the office were
talking about it takes six weeksto get in for a visit if you're
sick, right?
So, and even with littlechildren.
So, what I'm seeing, even youknow, among my colleagues, is a
(28:55):
willingness by, I mean, likeyoung parents to pay for
concierge medicine so that youdon't have to wait six weeks to
get your child seen for a cold.
Um, I think that's a tremendousopportunity.
Um, again, with you know, thecomfort level that we have with
APPs these days.
And, you know, it is analternative to urgent care,
(29:16):
right?
I mean, yes, you can take yourchild with the cold to the
urgent care, or you could signup for concierge medicine and
see the provider that you'refamiliar with.
And the provider has moreflexibility and can kind of
limit their patient population.
Um, it it seems like, you know,maybe even a throwback kind of
way to practice, which I thinkis a little old-fashioned and
lovely, where you really justget to focus on your patients
(29:38):
and be there for them.
SPEAKER_00 (29:39):
Well, it it it's interesting because this is what
my topic was when I was talking,is that um, you know, it's
membership based fees have canreally range, you know, every
anywhere from this executivehealth um where it could be 10
plus thousand a year to sign up,to a plan that might be in the
twelve hundred dollar a month uhAmount per year to sign up.
(30:02):
But then what do you get fromit?
You get direct access to yourcare provider by text or phone
the same day, sometimes same dayappointments, sometimes next
day.
I mean, that's a far cry thannine months.
And then whenever you actuallyare are um are seen by the by
the or seeing your provider, thetime may be 30, 45 minutes an
(30:27):
hour spent.
And now you're thinking, wow,this is really more of a
relational um type of uhtransaction than just purely
transactional.
Um and and and you when you whenyou think about it from the
provider standpoint, um, youknow, and we think in terms of
compensation per work RVU, Imean, it is through the roof,
(30:50):
not even comparable.
Like a primary care visit issomewhere in the$40 to$50 a work
RVU to the and in terms ofcompensation, but when you think
about it from a membership feesum to the number of visits,
you're looking at 200 plus.
So it just, I think the way Ilike to think of it is it
realigns where the value iscoming from.
(31:12):
It's not about, you know, when Ifirst started, it was, hey Joe,
take this two-patient a dayclinic and grow it to 40.
And if you can stomach 50, gofor it, uh, which was is crazy.
We did grow it, but that'scrazy.
To, hey, Joe, take these panelof patients and do the very best
(31:32):
you can for those patients andkeep them as healthy as possible
and as happy as possible, suchthat the membership rates that
they pay make sense for them.
And it's just a completelydifferent, you know, frame of
thinking.
But anyhow, it it made me think.
Like I said, I gave the talk onSaturday and I was sitting there
thinking, wow, what what what athrowback to sitting in
(31:57):
somebody's room and being ableto actually sit.
I'll I'll leave you with thisone just and we can switch gears
however y'all want to do it.
But uh, when I interviewed atone job, I went from you know
the back office, the nursingstation, all that stuff, and I
went to somebody, oh, here's ourtypical exam room.
And when they opened the door, Isaid, Well, wait, where's the
stool?
I was you know, just happygo-lucky, lit learn learn
(32:19):
learning everybody, everythingaround.
And how where's the stool?
And they said, Oh, we don't havestools, we don't want you
sitting down.
Okay.
This isn't gonna work.
Um, but uh, but so so theantithesis of you know, uh that
type of concierge practice.
SPEAKER_02 (32:34):
It'd be interesting, Joe, to see patient satisfaction
levels on the model you'retalking about versus you know
the model that we typically see.
I bet it's probably skyrocketedor patient satisfaction
significant in that conciergemodel.
SPEAKER_00 (32:46):
Absolutely.
I'll tell you right now, justjust um, and I was generous with
that three weeks.
I I don't know what I wastalking about, Emily.
But but um I I, you know, I asyou guys know, I was training
for the Iron Man event, uh,which I was super excited.
That's probably the only thing Iwanted to talk about, which is
why I'm finding a way to talkabout it here in the podcast.
Go for it.
SPEAKER_03 (33:07):
You deserve it.
SPEAKER_00 (33:08):
But but I had an abnormal lab because and and
that abnormal lab was on mykidneys.
And if you run an enduranceevent, you can stress your
kidneys further.
And so that panicked my wife,and that got me going.
And it took me an arm and a legand a couple of doctor friends
to get me into a primary care.
(33:28):
And at that time, I had alreadyordered tests, and I'd already,
as an NPE and as the with ourability to order tests for
ourselves, I did it.
And I sat in that first room andI said, here's what I want to
talk about.
I want to talk about can I dothe race or not?
It's a nine-month commitment,and I was already five months
into it.
And I don't think he looked upfrom his computer but twice, and
(33:50):
that was just to say hi, andthen the next one was to say,
let me reorder your labs.
And I'm like, wait a second, wejust ordered labs.
And there was, I left thatappointment after a drive to the
to the practice, sitting in theexam in the waiting room,
sitting in the exam room, andthen leaving out with an order
for another lab with like noanswers, and completely felt
(34:12):
like, okay, this was useless.
I did call a friend who I workedwith who is in concierge
medicine.
She immediately took my call.
We we we talked through it, andall is good.
But um, I think, judging by yourconversation, you mentioned
Emily, that's exactly what'shappening.
And as as if providers arewilling to do it, that price
(34:33):
point for the membership isslightly lower.
I think it's definitely gonnaresonate with people.
Um and I and I and again, Ithink that's an area that APPs
could do.
Thinking about you know,pediatrics, and uh it's just one
of my loves.
Um, you know, you you there's somuch education that being given
that parents they leave out ofan office in 10 minutes with an
(34:53):
ear infection of their firstchild who's two, screaming with
fever of 104.
I mean, they're still panickeduh about what to do at two in
the morning, you know, andthere's a lot of education you
can do.
But anyhow, interesting.
SPEAKER_04 (35:07):
Oh, it's great points.
And I think, you know, it kindof ties back into what we were
talking about about why APPsare, you know, we're seeing uh
such growth in this area becauseit helps with access and you
know helps give patients moreattention and time.
And I've got to believe that'smore gratifying for the
provider.
Another space where I see, youknow, a real need for um more
(35:31):
providers is in psychiatry.
I mean, the the wait is again,you know, maybe longer than nine
months to see a psychiatrist.
And those can be, you know, thatcan be extended using APPs to
assist the psychiatrists.
Um I know there are some specialbilling rules when we do
behavioral health.
Um, but again, I think as thosethings get figured out, we have
(35:55):
the opportunity to reallyimprove health care um for
everybody, make it moregratifying for the provider,
make it you know, better, havemore access for patients.
And I think APPs are atremendous component of that.
SPEAKER_00 (36:08):
I I I agree.
Uh that um I worked with a OBand he had three, four, I'm
sorry, APPs.
And and what he loved about itwas that he was able to gain an
extra day in the OR.
Um, and he ended up seeing mostof the complex cases that we had
(36:30):
already seen early on.
And so it just it and and us asAPPs, we love the time with the
patients and we love giving themguidance and we love that
aspect.
I mean, I think if we if we umplay to our strengths, um, I
think everybody becomes happier.
I mean, what the statistic thatum we said at one of our uh
(36:52):
talks was that um uh burnout isuh uh uh or or feeling some sort
of burnout is uh over 50% umwhen in the physician
population.
So certainly I think utilizingAPPs in in a better, more
efficient manner to theirlicense, up to their license,
will certainly I think helpphysicians um practice um
(37:17):
medicine that they want topractice.
SPEAKER_02 (37:20):
And there were in the webinar we talked about some
behavioral health flexibilities,as Emily touched on that for the
incident two billingrequirements are a little bit
more flexible to make sure thatthere's get that important
access that people are gettinguh the needed mental health
services that they need accessto.
And and the APPs and the use ofthem is gonna help uh promote
(37:40):
that.
SPEAKER_00 (37:42):
Absolutely.
And a person who is sufferingfrom anything, whether it be
mental or physical, um, caughtearlier, addressed earlier, it's
less expensive for the generalpopulation and better for that
individual.
I mean, it's just there's um alot of pluses to go around.
SPEAKER_02 (38:02):
So agreed, agreed.
Well, is there anything else,Joe, that we've that we failed
to highlight that we're I don'tthink so.
SPEAKER_00 (38:12):
I got my Iron Man in, so I'm good.
Um I'm kidding.
I'm sorry, I'm hooked.
I I I I want y'all to do it withme.
Uh but uh no.
SPEAKER_04 (38:24):
I'm training for a half marathon, and that's how
much I can go.
SPEAKER_00 (38:27):
Put on a whisk.
SPEAKER_04 (38:28):
So access to a good orthopedist or an orthopedist PA
is also important.
SPEAKER_00 (38:34):
There you go, there you go.
No, I I I I think we did great.
I I I love talking with youguys, and it's been super that
AHLA has given us the platformto uh again take our show on the
road.
And um uh certainly I wouldreach out to any of us, um,
especially if you have any ofthe legal questions, reach out
to my colleagues, Elena orEmily.
(38:55):
Um, and um thank you for joiningus.
SPEAKER_01 (39:03):
If you enjoyed this episode, be sure to subscribe to
AHLA Speaking of Health Lawwherever you get your podcasts.
For more information about AHLAand the educational resources
available to the health lawcommunity, visit
americanhealthlaw.org and stayupdated on breaking healthcare
industry news from the majormedia outlets with AHLA's Health
Law Daily Podcast, exclusivelyfor AHLA comprehensive members.
(39:26):
To subscribe and add thisprivate podcast feed to your
podcast app, go toamericanhealthlaw.org slash
daily podcast.
This episode of AHLA Speaking of Health Law is
sponsored by HMS ValuationPartners.
For more information, visitHMSvalue.com.
SPEAKER_00 (00:17):
Welcome everyone to this episode of AHLA's Speaking
of Health Law podcast.
I am very excited today for thisepisode on all things APP or
advanced practice providers withmy colleagues Alina Chrislip and
Emily Gray.
We had so much fun with thistopic just last month on a
(00:39):
webinar that we thought we'dtake the show on the road and
have even further conversationtoday.
With that, my name is JoeAguilar.
I am the managing partner withHMS Valuation Partners and have
focused my 30 plus years onphysician and APP compensation
along with fair market value andcommercial reasonless work.
(01:02):
With that, I'll pass it to mycolleagues to introduce
themselves.
And I guess we'll start withElena.
SPEAKER_02 (01:08):
Thanks, Joe.
Elena Chrislip.
I'm a healthcare regulatorycompliance lawyer, sort of the
general practitioner ofhealthcare law here in uh
Charleston, West Virginia atJackson Kelly PLLC.
SPEAKER_04 (01:23):
And I am Emily Gray, and like Elena, I have kind of a
broad regulatory practice.
I'm located in Baton Rouge,Louisiana, where I am a partner
at Brazil, Saxe and Wilson, andI'm on the firm's management
committee.
And in my 25 years, I'verepresented a variety of
healthcare providers of allshapes and sizes.
SPEAKER_00 (01:46):
All right.
Well, I think as I think backwhen we first started connecting
on this, because we actuallytalked on or presented, I should
say, in February with theadvising providers conference.
What struck me to on this topicwas just the continued use of
APPs.
(02:06):
As a nurse practitioner myself,which I started 20 plus years
ago, it was primarily just a fewspecialties, and now they they
seem to be integrated into notonly the specialties, but even
the subspecialties.
(02:29):
MGMA just recently uh put out apoll and which uh asked medical
groups what percentage of the umof them were thinking about
adding new APP positions, and itwas over 65 percent, um, which I
I I find remarkable justthinking back you know 20 plus
(02:50):
years ago as a student.
But um that obviously has led toum the I guess the legal
profession and compliance folksto figure out ways to do it
right um and avoid um any anypitfalls.
I guess um I'll I'll leave it uhgive it up to you, Elena or or
Elena, sorry, or um or Emily uhas to um you know how how do you
(03:16):
see that growth impacting umwhat you're seeing on a
day-to-day basis with APPs andyour clients.
SPEAKER_04 (03:24):
I'll jump in real quickly.
One of the things I wasthinking, Joe, as you were
speaking, is that part of theevolution we're seeing is kind
of the evolution in our overallpopulation, right?
As we have, you know, kind ofour a number of physicians, kind
of a silver tsunami aging out,um, looking at using our
resources wisely and extendingphysicians as best we can with
(03:48):
APPs, I think makes a realdifference in the healthcare
space and the delivery of care.
And I think that's perhaps partof why we're seeing, you know,
the the increase in the numbers,um, and just that it works.
SPEAKER_02 (04:01):
I I would agree with that.
I I also don't know, you know,because of I still feel like
things are still backed upbecause of the the COVID, the
public health emergency.
We still have a lot of backlogswith physicians, and you know,
if you can't multiply yourself,how how do you extend yourself,
right?
And the use of APPs both inhospital settings and and
outpatient settings, I think ishelping, you know, to to address
(04:23):
and make sure that physicians umare meeting and and seeing all
of their patients to the extentthat they can.
SPEAKER_04 (04:31):
And I think patients are more comfortable with APPs
now than they were maybe 10 or20 years ago.
Um you know, I think about myparents who were more like, I
want to see the doctor, um, asopposed to folks who are really
happy with the level of accessand the level of care that's
provided with APPs more now.
SPEAKER_00 (04:52):
I mean, I think that that certainly resonates with me
because um 20, 22, 23 years ago,um the concept of the nurse
practitioner even mentioningthat I was going back to school
uh to Hopkins to seek thisdegree uh just was um not really
understood by the generalpublic.
And now you're seeing nursepractitioners in the
(05:12):
commercials, uh, you're seeingum shoot even hitting the big
time with Netflix, uh, what'sthat series, Virgin River, uh,
with their with their lead uhlead um heroine uh as a nurse
practitioner.
But um but no, I I I agree.
What's what's what's beeninteresting in this is I I've
been able to get the opportunityto talk with provider
(05:34):
compensation specialists acrossthe country, and they brought
together a panel of APPs thatare actually certified in
rheumatology, in neurology, andall these sub-specializations,
and they're being certified inthat manner because um
organizations are put puttingtogether fellowships um for APPs
as well.
So I it's it it's just changedthe landscape tremendously.
SPEAKER_02 (05:58):
I I don't think we should lose sight either, Joe,
and and you probably know thisbetter than anybody that in in a
lot of states, a majority ofstates, nurse practitioners can
hang up their own shingle aswell.
And so, you know, to the extentwe start getting into some of
these billing rules, nursepractitioners based on state law
can also delegate, right, andand be functioning uh in in that
role where they're delegating toothers.
(06:19):
So I I think that's kind of animportant point as well, that
they can themselves hold uptheir own shingle um depending
on the state law involved.
SPEAKER_04 (06:27):
That is so true, Elena.
Um, and in you know, ourpresentations, I was kind of
focused on the state law.
And even in a matter of sixmonths, there were changes
where, you know, Arkansas, forexample, I had to go back and
make updates because theyallowed autonomous practice for
their NPs and just changed thelaw very quickly.
And I think that's a trend thatwe're seeing in the states.
(06:49):
I think, you know, with thisincrease in comfort with the
APPs, we're seeing states givethem, you know, kind of broader
authority.
SPEAKER_02 (06:58):
And I think, Emily, too, and Joe, maybe you can
speak to this.
I mean, there is a workforceshortage, right, from the
healthcare perspectivegenerally, and that might also
be, you know, uh one of theimpetuses for for states wanting
these folks to have moreautonomous ability to operate on
their own to help address theworkforce shortage.
SPEAKER_00 (07:18):
I completely agree.
I I I I think um, and this isprobably a topic for another
podcast, but even the idea oftraining APPs um and how are
they trained, um, what type ofum clinical experience do they
have while they're in school?
Is there a role for even aresidency program for APPs in
(07:42):
the future with so manyresidency spots going unmatched,
as well as you know, communitiesnot necessarily being fully
serviced?
So I I think there's a lot thatI uh you know, what is our topic
called?
Charting the future.
I I I think there's a lot ofpathways for the future of APP
practice, there's there's nodoubt.
(08:03):
And I also think it makes sensejust from the models uh you know
standpoint, um, you know, whenyou think about primary care uh
and and your first newappointment is three weeks out,
uh it that just doesn't makesense that you don't have
advanced practice providersbeing able to see that patient
because they can handle the vastmajority of primary care within
(08:24):
the scope.
Um and then when you think aboutthe um subspecialties like you
know neurology or endocrinology,there's a lot of ways that they
can extend um, or even thesurgical practices where they're
dealing with follow-up or orpre-surgery assessments.
Um there's lots of ways thatthey can um really facilitate
(08:45):
the care of more more patientsas as as um we mentioned.
But I I guess and this has beenan issue for us uh for me ever
since I was uh a new NP, is allthe billing nuances um that
arise with this.
Um I mean what do you all see assome of the challenges there to
(09:08):
keep you know health systems astheir employers or APPs in
general um on the straight andnarrow with regards to billing?
SPEAKER_02 (09:16):
Yeah, so I mean that's a that's a great point.
I mean, short of direct billing,right?
And and making sure that youknow you're meeting medical
necessity and billing under thepractitioner, either the
physician or or other APPs ownMPI number, you're there are you
know incident two and outpatientsettings, um, and then there's
split shared and institutionalsettings.
And I think that you know it'scritical compliance for for
(09:39):
meeting these um billing rulesis is important for for entities
and making sure that you havethe appropriate documentation,
reflecting that you're meetingall of the specific rules
involved with with each of thetypes of billing rules.
SPEAKER_00 (09:56):
Yeah, no, I mean I I think do do y'all find um are
y'all getting a lot of questionson that subject as as health
systems dive into more and moreuse of APPs?
SPEAKER_04 (10:07):
I'm not seeing so much questions with the billing
requirements as I am, you know,and I'm just thinking this week
we saw some questions um for aprovider who has, you know, the
physician was out on vacationand then saw an unusual number
of patients, you know, using hisNPs.
And I think there is somescrutiny there, um, and you have
(10:30):
to be real careful about thebilling um and and how you're
handling it, particularly withyou know, if you're trying to do
a high volume of patients uhunder a single supervision
supervising physician.
SPEAKER_00 (10:45):
Yeah, that I mean I that's an interesting comment
because we've seen um a coupleof situations where, and again,
this is state by state umdriven, but where a single
physician may be supervisingthree or upwards of ten or more
APPs, and you know, what'swhat's okay, what's not okay,
(11:05):
even beyond what the state regssay in the moment.
SPEAKER_02 (11:08):
Um and I would argue to show that you're you're
you're when you're billing,you're saying you're meeting all
the billing requirements and allrequirements under state law.
So if you're supervising moreAPPs than maybe you should be, I
think there's an open questionas to whether or not you've been
actually meeting all therequirements to bill, um,
depending on how you bill thoseservices.
So um I don't know, Emily.
(11:29):
I know that you in yourpresentation you gave a lot of
like the specifics from state tostate as to how many, you know,
APPs a physician could couldoversee.
So I don't know if you have anyother thoughts on that.
Yes, y'all lined that up for meperfectly.
SPEAKER_04 (11:44):
Um thank you.
That's my cue.
Um, really, one of the thingsthat's that's critical when
you're setting these up ismaking sure that you're familiar
with what the state lawrequires.
Um, there are tremendousvariances in supervision ratios
state by state.
Um, some states like Arizona andColorado don't require any
(12:06):
physician supervision.
Um other states have aggregatelimits.
So, you know, in looking at someof these, and I gave a laundry
list of states and requirementsin the presentation.
Um, but they're, you know, ifyou've seen one state, you've
kind of seen one state.
South Carolina has a limit ofsix in the aggregate, NPs are
(12:27):
PAs.
Alabama has a limit forphysicians that can only
supervise up to 360 hours perweek, which are nine FTEs of NPs
and PAs.
Some have limits on PAs, but notNPs, like in Delaware,
physicians can collaborate withfour PAs and no limit on NPs.
(12:47):
Louisiana, my state, uh aphysician, there's no limit on
NPs.
That limit was removed, gosh,probably 10 years ago.
But there's a limit of eightPAs.
Um, and then some states requireyou to have backup physicians in
addition to that one supervisingphysician.
So there is a lot of variance.
SPEAKER_00 (13:06):
Yeah, and so thinking about supervision, so
at when I practiced, um I I haduh the pleasure of actually
having a separate clinic where Iwas connected to my um
collaborating physiciantelephonically.
So if there was a need, they youknow, I I could call them.
Um but I know that you know withincident two and other and other
(13:28):
type of billing rules, there'skind of certain restrictions or
regulatory requirements to meetthose rules.
I think uh Elena, you spoke onsome of those, um, even specific
to like location of thephysician.
SPEAKER_02 (13:42):
Yeah.
So for for incident tworequirements, the um incident
two billing requirements orbilling rule, you know, the
physician has to uh providedirect supervision to the um the
provider that they are are umbilling the service incident to.
I did want to clarify that itcan't, you know, it's a patient
if you're if it's incident tothe physician, right?
(14:03):
It's a patient that's alreadycome in that the physician seen
developed a treatment plan for,and the the APP is is reviewing
the plan of care and you know,just evaluating the patient
consistent with what uh thephysician has already developed.
And so as far as the directsupervision, they have to be
present in the office suite andimmediately available to furnish
(14:24):
assistance.
And so depending on the Macinvolved, if there's any
questions, you know, you canhave a discussion with your Mac,
but it's also sort of a commonsense type approach.
Um, if you have a suite on thefirst floor and you also have a
suite on the third floor, youknow, and your physician's on
the third floor and your APP'son the first floor, that's
probably not really directsupervision.
Um, I think there's even aquestion, depending on the Mac,
(14:46):
if you have an L-shaped suiteand the physicians at one end
and the APP's at the other, andyou can't really, they can't
hear you, right?
Unless you have some sort oftelecommunication or um intercom
system in the in the suite, thatthere might be a question as to
whether or not that is actuallydirect supervision.
And so they have to be availablefor questions.
(15:07):
Short bio breaks are okay, but Imean, if they're otherwise
involved involved in in treatinganother patient or in the middle
of a procedure and wouldn't beavailable, I think there's a
question of whether or notthey're meeting direct
supervision.
And and kind of going back tothe compliance uh part you
mentioned earlier, Joe, is Ithink that the the doctor should
document, right, in the recordwho was the, you know, or the
(15:28):
APP, who was the physician or orthe person who was providing um
the direct supervision for theincident two service to be
billed.
SPEAKER_04 (15:37):
The devil really is in the details.
I mean, it seems so persnicketyfor the health lawyers to say,
okay, it matters if yourbuilding is L-shaped or if
you're on the second floor orthe first floor with your NP.
It's um uh remarkable how howdetailed and careful they have
to be.
And if you multiply a problem bya year or two years, um, it
(15:59):
starts adding up to be a reallyexpensive problem potentially.
SPEAKER_00 (16:03):
I agree.
I I I I just out of curiosity, Imean, uh do y'all are y'all
seeing incident two questionsmore prevalent with your
hospital health system clientsversus your private medical
groups?
Um and the only reason I ask isbecause we're we're seeing a lot
of health systems seem to wantto move the way of direct
(16:25):
billing and not necessarilyusing the NPI number of the
APPs.
And but yet when you've gotthese medical groups that either
uh joint venture or becomeacquired, um which they still
are, it's still happening, um,you see the medical groups being
more comfortable billingincident two.
Um no doubt avoidance of the 85%reduction or 85% reimbursement
(16:47):
rate.
But just curious if if you guysare seeing any particular type
of clients for this question.
SPEAKER_02 (16:55):
To move to the to to try to uh obtain the maximum
amount of reimbursement.
Yeah, I think I think that'salways you know on on the you
know a matter of evaluation in abusiness decision, right?
Because as we we've pointed outhere and in our uh webinar,
there are compliance risksassociated if you're not meeting
the billing requirements.
(17:16):
And so especially um, you know,there can be some substantial
paybacks with with both shared,you know, split shared um
billing and incident twobilling.
And so I do, I do think to yourfirst point there, Joe, you're
seeing a lot of folks say, well,it's not worth the headache.
We know operationally we're notgonna document the requirements
to meet this if we're everaudited.
(17:38):
Um, so we're just gonna directbill, right?
To the extent that ourphysician, our nurse
practitioner, our folks candirect bill, we're gonna just
have them bill under their MPInumbers and we're willing to
take that 85% reimbursementversus the 100%, you know, the
physician fee schedule because,you know, we can sleep better at
night knowing that we don't havethese open compliance risks that
(17:59):
we need to be auditing for.
SPEAKER_00 (18:01):
Yeah, yeah.
SPEAKER_04 (18:03):
Well, and uh my experience is is similar.
And I think when I look at youknow, my practice, we get more
questions from medical groups,um, and they seem often more
willing to uh push the envelope,perhaps, uh, than some of the
health systems.
Um, and you know, they may haveless questions, or I think they
have less questions becauseprobably they're more
(18:24):
sophisticated and morerisk-averse.
SPEAKER_00 (18:27):
Yeah.
SPEAKER_04 (18:28):
Um so that that's been what I've seen.
SPEAKER_00 (18:30):
And I think that it lends itself better to certain
specialties and certain modelswhere the APPs are working.
So, like if you're primary careand trying to do incident two,
that's super hard.
I mean, Mrs.
Jones comes in for a follow-upon her diabetes, and and the
diabetes may be the initialdiagnosis that you're down
billing the incident twofollow-up care on, but she's got
(18:52):
a cold.
And now you're what are yougonna do?
Like, well, sorry, you can't seeme for the cold.
Uh, you know, and there arethere are ways you can do it,
but it requires a lot of youknow jumping through hoops.
But if I am um you know workingas the diabetes educator at in
an endocrinology practice, andmy patients are pretty you know
routinely coming in for justtheir diabetes care, I mean,
(19:15):
then it makes complete sense totry to set up a system that
allows you to bill, you know,instant two under the guise of
following at least thatcomponent of the rule.
But um, yeah, it it's it thatthat that's always been
interesting ever since I startedpracticing and how how to how to
navigate that just as an NP.
SPEAKER_02 (19:33):
Yeah, and I I was just envisioning and again, I'm
not I'm not a technologicalperson myself, but I'm thinking
that technologically there's gotto be something that I was
thinking through in an EMRsystem, for example, right?
If they're coming in for theirdiabetes and you're putting in
an additional diagnosis, in mymind that should send off bells
and whistles, right?
Or or or flag that in some wayfor your billing folks to know
(19:55):
that's a new, that they'recoming in for a new condition,
right?
And so this should not be buildincident too.
And I'm thinking in discussionswith EMR uh vendors, there's got
to be a way maybe to flag thateven internally so your your
folks on the billing side wouldknow that's gotta be billed
differently and can't be buildincident to.
SPEAKER_00 (20:13):
Yeah, agreed.
I'm not sure if that's thatthat's in place.
SPEAKER_02 (20:16):
Um I don't know, but hopefully a vendor out there
after hearing this will put itin place.
SPEAKER_00 (20:21):
I know a few of them.
I I should have thatconversation with them.
Well, I and and I'm not gonnaI'm gonna try to switch gears uh
a little bit and we'll just keepthe conversation rolling.
But um, you know, you mentioned,Elena, that NPs are able to hang
their own shingle on things.
Um, and it doesn't always haveto be in that capacity.
(20:43):
But I know, Emily, you spoke onon the webinar as well as the
the um the presentation we didat the conference up on
innovative ways of using APPs,and that you know, you're often
hit with kind of first-timequestions of, hey, can we do
this?
Um maybe you can shed a littlelight on how you approach those
(21:05):
questions.
SPEAKER_04 (21:07):
Sure.
And you know, that's really beenum fascinating and fun, and you
get to be a little creative, Iguess.
Um one of the things that I'veseen in the last few years are
some entrepreneur types um whoare looking to establish you
know virtual clinics withoutbrick and mortar, uh, which is
(21:28):
something I think, again, aswe've seen the evolution of you
know, healthcare, we see folksmuch more comfortable with
telehealth, much less need ofhaving an office.
I think that's something thatthe pandemic brought to us.
Everybody learned uh how to doZoom.
Um so what we're seeing is umyou know providers taking
(21:49):
advantage of this and lookingfor ways uh to bring care to
people in their homes, not tohave to have bricks and mortar.
Um I see folks coming in wantingto do things across state
borders in different states.
Often they come to me and say, Ihave this idea, let's start it
here, but we want to set it upin a way that we can go
(22:11):
national, right?
And so what do we look at firstwhen we do that?
Um, if we're working within-house counsel, I give them a
little bit of guidance.
And if I'm working directly withthe business people, um, you
know, I do my best to help themput on the brakes a little bit
sometimes.
Um the business folks seem to bevery eager and quick.
(22:33):
I had one group that thought,you know, as long as I get
authorized to do business in thestate, we can pretty much do
whatever we want, right?
It's like, whoa, you know, slowdown.
You know, folks need to belicensed.
We have all different kinds ofrules in every state, uh, which
I went into in in great detailin our uh in our presentations.
But I think that's somethingthat's critical when new folks
(22:54):
come in with, you know, afantastic idea, helping them
understand and navigate thedifferent pieces.
So, for example, if you're notgonna have bricks and mortar,
we're gonna have to talk aboutwho your payers are.
Are you doing a pilot project uhwith an MCO or are you gonna try
and build Medicare and Medicaid?
And if you're gonna try andenroll in Medicare, you're gonna
(23:17):
have some issues because there'san enrollment requirement that
you're operational, which meansyou have a physical location.
How are we gonna handle that?
Um, you know, I've had folkslooking at um office sharing uh
type situations and kind ofdefeats the whole purpose.
So, can you use someone's home?
How is it gonna work?
(23:37):
So, kind of getting throughthose issues first, talking
about workforce that might berequired by whatever state law
ratio there is for supervisionis important.
Um, those are kind of some keyconsiderations at first, and and
helping um our fast-movingbusiness folks to understand you
need to set it up right, or youmight have to give all the money
(23:59):
back.
Um or you know, you might getyour providers in trouble.
I've represented a couple ofdifferent providers.
One was in the state ofLouisiana where, you know, he
relied on the company who, youknow, engaged me to help the
provider.
Um, but they were missing acouple of disclosures on their
state-specific telehealth umconsent form.
(24:21):
And we got to go talk toLouisiana State Board of Medical
Examiners.
And with the companies I'vetalked to looking to do this
with the providers, myexperience has been that they
are unanimously, you know,behind their providers, don't
want anybody gettingdisciplined, don't want to hang
them out there and areprotective of the providers, but
understanding those risks to thelicenses of the physicians and
(24:45):
the nurse practitioners, andit's mostly nurse practitioners
that I see in these models, um,that's important.
Um, there are some you knowprescribing limitations.
There's one state, it's mine,uh, that has special rules on
prescribing obesity drugs.
Uh you can't do it viatelehealth.
And understanding all thoselittle nuances are are critical
(25:05):
in looking up, uh setting upthose uh virtual practices.
SPEAKER_02 (25:11):
And and that's kind of there were some public
health, you know, emergencyflexibilities that went through
that are at least some of themare going through the end of
this year.
And then the 2025 physician feeschedule adopted certain
flexibilities if you met certainrequirements.
And now I know the 2026physician fee schedule is
anticipating or at least isproposing to, you know, uh do
(25:32):
sort of all for all incident twoservices, um, more of a
broad-based um exception.
And so that's something justkind of to keep an eye on for
folks that are billing for someof these supervision
requirements, Emily.
I was tying on to your virtualaspect there, that there were
some flexibilities there from avirtual perspective that folks
should be aware of um and makesure they look into because you
(25:54):
may not have to have thatphysician for certain things
that you're billing directly inthe office, they can they can um
attend it virtually via sometype of audio video
communication.
SPEAKER_00 (26:06):
I I um along the lines of innovation, um I I just
attended a uh the annualconference for concierge
medicine today here in Atlanta.
Um and what's what's interestingabout the group or just the
concept is that I think you'restarting to see some APPs even
(26:27):
do it in certain states.
Um have have has that evercrossed y'all's desk?
Uh I mean, I because what whatwhat I'm thinking about is those
practices that not necessarilythe primary care, but the ones
that get more niche, like eitheryour a longevity practice or
your uh you know, dealing withbiodentical hormones or or
something along those lines.
Um because as I was sittingthere, I was thinking, wow, as a
(26:49):
as an APP, you know, this couldbe another means of of of um
developing a practice,developing a following with
patients, and and um potentiallyyou know aligning you know a
work-life balance or that whichproviders typically love to do,
which is spend time withpatients versus spend time with
(27:10):
all the administrative stuff.
I'm just curious if that's everhit y'all's desk by any chance.
SPEAKER_02 (27:15):
It yeah, we're seeing a lot more of that,
especially in the um, I don'tknow what you would call it, the
cosmetic realm of the case.
Where you know aesthetics, yeah,the aesthetics, you're seeing a
lot more of that.
Um, and and generally when Ihear concierge medicine, I I
think cash only, um, notparticipating in Medicare,
Medicaid.
And so um I yeah, I think you'reseeing a lot more of that.
(27:38):
And I think they're lucrativepractices.
You just have to make sure, youknow, again, you're you're
following all your compliancerequirements that you need to
meet under the state law whereyou're providing that service.
And if you, you know, if you gotto double check and make sure
you're not enrolled, you know,as participating in Medicare and
things like that, because I havehad some situations where the,
you know, physicians they'reproviding hospital services,
(28:00):
right?
And they've reassigned theirbenefits to bill and collect to
the hospital for purposes ofMedicare, but they're over here
trying to set up a practice thatdoesn't accept Medicare and it
doesn't necessarily jive.
unknown (28:12):
Yeah.
SPEAKER_04 (28:14):
Well, and anecdotally, you know, as we're
talking about kind of thingsevolving and having more of a
role for the APPs, um, you know,one of the things we were
talking about, you know, aroundthe office recently is how long
it takes to get in with people.
Joe, you were very generous atthe beginning of the
presentation saying, oh, ittakes three weeks.
SPEAKER_00 (28:34):
Yeah.
SPEAKER_04 (28:35):
You know, in my community, it takes nine months
to get in with a new TPP as anew patient.
And, you know, some of the um mycolleagues in the office were
talking about it takes six weeksto get in for a visit if you're
sick, right?
So, and even with littlechildren.
So, what I'm seeing, even youknow, among my colleagues, is a
(28:55):
willingness by, I mean, likeyoung parents to pay for
concierge medicine so that youdon't have to wait six weeks to
get your child seen for a cold.
Um, I think that's a tremendousopportunity.
Um, again, with you know, thecomfort level that we have with
APPs these days.
And, you know, it is analternative to urgent care,
(29:16):
right?
I mean, yes, you can take yourchild with the cold to the
urgent care, or you could signup for concierge medicine and
see the provider that you'refamiliar with.
And the provider has moreflexibility and can kind of
limit their patient population.
Um, it it seems like, you know,maybe even a throwback kind of
way to practice, which I thinkis a little old-fashioned and
lovely, where you really justget to focus on your patients
(29:38):
and be there for them.
SPEAKER_00 (29:39):
Well, it it it's interesting because this is what
my topic was when I was talking,is that um, you know, it's
membership based fees have canreally range, you know, every
anywhere from this executivehealth um where it could be 10
plus thousand a year to sign up,to a plan that might be in the
twelve hundred dollar a month uhAmount per year to sign up.
(30:02):
But then what do you get fromit?
You get direct access to yourcare provider by text or phone
the same day, sometimes same dayappointments, sometimes next
day.
I mean, that's a far cry thannine months.
And then whenever you actuallyare are um are seen by the by
the or seeing your provider, thetime may be 30, 45 minutes an
(30:27):
hour spent.
And now you're thinking, wow,this is really more of a
relational um type of uhtransaction than just purely
transactional.
Um and and and you when you whenyou think about it from the
provider standpoint, um, youknow, and we think in terms of
compensation per work RVU, Imean, it is through the roof,
(30:50):
not even comparable.
Like a primary care visit issomewhere in the$40 to$50 a work
RVU to the and in terms ofcompensation, but when you think
about it from a membership feesum to the number of visits,
you're looking at 200 plus.
So it just, I think the way Ilike to think of it is it
realigns where the value iscoming from.
(31:12):
It's not about, you know, when Ifirst started, it was, hey Joe,
take this two-patient a dayclinic and grow it to 40.
And if you can stomach 50, gofor it, uh, which was is crazy.
We did grow it, but that'scrazy.
To, hey, Joe, take these panelof patients and do the very best
(31:32):
you can for those patients andkeep them as healthy as possible
and as happy as possible, suchthat the membership rates that
they pay make sense for them.
And it's just a completelydifferent, you know, frame of
thinking.
But anyhow, it it made me think.
Like I said, I gave the talk onSaturday and I was sitting there
thinking, wow, what what what athrowback to sitting in
(31:57):
somebody's room and being ableto actually sit.
I'll I'll leave you with thisone just and we can switch gears
however y'all want to do it.
But uh, when I interviewed atone job, I went from you know
the back office, the nursingstation, all that stuff, and I
went to somebody, oh, here's ourtypical exam room.
And when they opened the door, Isaid, Well, wait, where's the
stool?
I was you know, just happygo-lucky, lit learn learn
(32:19):
learning everybody, everythingaround.
And how where's the stool?
And they said, Oh, we don't havestools, we don't want you
sitting down.
Okay.
This isn't gonna work.
Um, but uh, but so so theantithesis of you know, uh that
type of concierge practice.
SPEAKER_02 (32:34):
It'd be interesting, Joe, to see patient satisfaction
levels on the model you'retalking about versus you know
the model that we typically see.
I bet it's probably skyrocketedor patient satisfaction
significant in that conciergemodel.
SPEAKER_00 (32:46):
Absolutely.
I'll tell you right now, justjust um, and I was generous with
that three weeks.
I I don't know what I wastalking about, Emily.
But but um I I, you know, I asyou guys know, I was training
for the Iron Man event, uh,which I was super excited.
That's probably the only thing Iwanted to talk about, which is
why I'm finding a way to talkabout it here in the podcast.
Go for it.
SPEAKER_03 (33:07):
You deserve it.
SPEAKER_00 (33:08):
But but I had an abnormal lab because and and
that abnormal lab was on mykidneys.
And if you run an enduranceevent, you can stress your
kidneys further.
And so that panicked my wife,and that got me going.
And it took me an arm and a legand a couple of doctor friends
to get me into a primary care.
(33:28):
And at that time, I had alreadyordered tests, and I'd already,
as an NPE and as the with ourability to order tests for
ourselves, I did it.
And I sat in that first room andI said, here's what I want to
talk about.
I want to talk about can I dothe race or not?
It's a nine-month commitment,and I was already five months
into it.
And I don't think he looked upfrom his computer but twice, and
(33:50):
that was just to say hi, andthen the next one was to say,
let me reorder your labs.
And I'm like, wait a second, wejust ordered labs.
And there was, I left thatappointment after a drive to the
to the practice, sitting in theexam in the waiting room,
sitting in the exam room, andthen leaving out with an order
for another lab with like noanswers, and completely felt
(34:12):
like, okay, this was useless.
I did call a friend who I workedwith who is in concierge
medicine.
She immediately took my call.
We we we talked through it, andall is good.
But um, I think, judging by yourconversation, you mentioned
Emily, that's exactly what'shappening.
And as as if providers arewilling to do it, that price
(34:33):
point for the membership isslightly lower.
I think it's definitely gonnaresonate with people.
Um and I and I and again, Ithink that's an area that APPs
could do.
Thinking about you know,pediatrics, and uh it's just one
of my loves.
Um, you know, you you there's somuch education that being given
that parents they leave out ofan office in 10 minutes with an
(34:53):
ear infection of their firstchild who's two, screaming with
fever of 104.
I mean, they're still panickeduh about what to do at two in
the morning, you know, andthere's a lot of education you
can do.
But anyhow, interesting.
SPEAKER_04 (35:07):
Oh, it's great points.
And I think, you know, it kindof ties back into what we were
talking about about why APPsare, you know, we're seeing uh
such growth in this area becauseit helps with access and you
know helps give patients moreattention and time.
And I've got to believe that'smore gratifying for the
provider.
Another space where I see, youknow, a real need for um more
(35:31):
providers is in psychiatry.
I mean, the the wait is again,you know, maybe longer than nine
months to see a psychiatrist.
And those can be, you know, thatcan be extended using APPs to
assist the psychiatrists.
Um I know there are some specialbilling rules when we do
behavioral health.
Um, but again, I think as thosethings get figured out, we have
(35:55):
the opportunity to reallyimprove health care um for
everybody, make it moregratifying for the provider,
make it you know, better, havemore access for patients.
And I think APPs are atremendous component of that.
SPEAKER_00 (36:08):
I I I agree.
Uh that um I worked with a OBand he had three, four, I'm
sorry, APPs.
And and what he loved about itwas that he was able to gain an
extra day in the OR.
Um, and he ended up seeing mostof the complex cases that we had
(36:30):
already seen early on.
And so it just it and and us asAPPs, we love the time with the
patients and we love giving themguidance and we love that
aspect.
I mean, I think if we if we umplay to our strengths, um, I
think everybody becomes happier.
I mean, what the statistic thatum we said at one of our uh
(36:52):
talks was that um uh burnout isuh uh uh or or feeling some sort
of burnout is uh over 50% umwhen in the physician
population.
So certainly I think utilizingAPPs in in a better, more
efficient manner to theirlicense, up to their license,
will certainly I think helpphysicians um practice um
(37:17):
medicine that they want topractice.
SPEAKER_02 (37:20):
And there were in the webinar we talked about some
behavioral health flexibilities,as Emily touched on that for the
incident two billingrequirements are a little bit
more flexible to make sure thatthere's get that important
access that people are gettinguh the needed mental health
services that they need accessto.
And and the APPs and the use ofthem is gonna help uh promote
(37:40):
that.
SPEAKER_00 (37:42):
Absolutely.
And a person who is sufferingfrom anything, whether it be
mental or physical, um, caughtearlier, addressed earlier, it's
less expensive for the generalpopulation and better for that
individual.
I mean, it's just there's um alot of pluses to go around.
SPEAKER_02 (38:02):
So agreed, agreed.
Well, is there anything else,Joe, that we've that we failed
to highlight that we're I don'tthink so.
SPEAKER_00 (38:12):
I got my Iron Man in, so I'm good.
Um I'm kidding.
I'm sorry, I'm hooked.
I I I I want y'all to do it withme.
Uh but uh no.
SPEAKER_04 (38:24):
I'm training for a half marathon, and that's how
much I can go.
SPEAKER_00 (38:27):
Put on a whisk.
SPEAKER_04 (38:28):
So access to a good orthopedist or an orthopedist PA
is also important.
SPEAKER_00 (38:34):
There you go, there you go.
No, I I I I think we did great.
I I I love talking with youguys, and it's been super that
AHLA has given us the platformto uh again take our show on the
road.
And um uh certainly I wouldreach out to any of us, um,
especially if you have any ofthe legal questions, reach out
to my colleagues, Elena orEmily.
(38:55):
Um, and um thank you for joiningus.
SPEAKER_01 (39:03):
If you enjoyed this episode, be sure to subscribe to
AHLA Speaking of Health Lawwherever you get your podcasts.
For more information about AHLAand the educational resources
available to the health lawcommunity, visit
americanhealthlaw.org and stayupdated on breaking healthcare
industry news from the majormedia outlets with AHLA's Health
Law Daily Podcast, exclusivelyfor AHLA comprehensive members.
(39:26):
To subscribe and add thisprivate podcast feed to your
podcast app, go toamericanhealthlaw.org slash
daily podcast.
Popular Podcasts
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
The Joe Rogan Experience
The official podcast of comedian Joe Rogan.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.