NAHC has major concerns it will be addressing with CMS
On April 27, 2022, the Centers for Medicare & Medicaid Services (CMS) issued Change Request 12615 to clarify requirements for allowed practitioners under the home health benefit.
In the “Background” section of the transmittal, CMS states that nurse practitioners and clinical nurse specialists acting as “allowed practitioners” under the Medicare home health benefit must work in collaboration with a physician, as well as in accordance with state practice laws, and that nurse practitioners must document their scope of practice and the relationships they have with physicians with whom they are collaborating in the medical record.
CMS reiterates, in the transmittal, the regulations at §410.74, §410.75, and §410.76 in the manual section at 30.2.1.
30.2.1 – Definition of an Allowed Practitioner
Allowed practitioners in addition to physicians, can certify and recertify beneficiaries for eligibility, order home health services, and establish and review the care plan. Allowed practitioners are defined at § 484.2 as a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) as defined at this part. NPs, CNSs, and PAs are required to practice in accordance with state law in the state in which the individual performs such services. Physician assistant means an individual as defined at § 410.74(a) and (c). Clinical nurse specialist means an individual as defined at § 410.76(a) and (b), and who is working in collaboration with the physician as defined at § 410.76(c)(3). Nurse practitioner means an individual as defined at §410.75(a) and (b), and who is working in collaboration with the physician as defined at §410.75(c)(3).
Individual states have varying requirements for conditions of practice, which determine whether a practitioner may work independently without a written collaborative agreement or supervision from a physician, or whether general or direct supervision and collaboration is required.
In the absence of State law governing collaboration, collaboration is to be evidenced by NPs documenting their scope of practice in the medical record, and indicating the relationships that they have with physicians to deal with issues outside their scope of practice.
CMS’ policy is both confusing and concerning regarding what CMS might be requiring of NPs in terms of collaboration in states where NPs have full practice authority (FPA). The National Association for Home Care & Hospice (NAHC) requested that CMS provide guidance on what the Medicare Administrative Contractors will be requiring for medical review. CMS responded as follows:
“…the contractors will only be looking for a statement in the medical record documenting the NPs scope of practice and indicating the relationships that they have with physicians to deal with issues outside their scope of practice, when the NP is NOT required to have a collaborative agreement. In other words, in states that do not govern collaboration.”
CMS further clarified that it considers states with full practice authority NPs to be states that do not have laws that govern collaborative agreements.
NAHC disagrees with CMS interpretation of the requirements for NPs with FPA. The regulation requires collaboration for NPs to be in accord with state laws. Additionally, section 3708 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which includes the provision for NPPs to certify and order home health services, only requires that NPPs practice in accord with state laws and is silent regarding collaborative agreements with physicians.
NAHC is working with the American Association for Nurse Practitioners to bring our concerns to CMS in order to reach an acceptable resolution.
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