Independent Practice Guidelines Q&A
Hello everyone! I get a lot of questions from Nurses, Nurse Practitioners and Certified Registered Nurse Anesthetists (CRNAs) about how they can start their own clinics, so I thought that I would answer a few of your questions here today.
Q: What states are independent practice states?
A lot of states now allow CRNAs to practice independently. Below is a map of the US showing which states are independent.
Q: Can I, as a Nurse, Nurse Practitioner or CRNA, legally open my own clinic?
A: The devil is in the details, here. It all depends on your state’s laws about how you can remain within your scope of practice. A few states require medical professional ownership (or at least part-ownership). California is one of these (the last time I checked). So if you do not hold a professional license through your state's Board of Nursing, then you will want to look into what is required to open a clinic without having a professional license.
The next thing to look, at is the Nurse Practice Act. So in every state, the Nurse Practice Act outlines what the scope of practice is for all nursing specialties including RN’s, LPNs and even Nursing Aids. Every state has slightly different language. Some states even restrict ketamine administration by a Registered Nurse (RN).
Some states allow independent functioning without a physician for Nurse Practitioners or Nurse Anesthetists, so those are absolutely the best states to practice in if you hold a license in those specialties. Typically, you'll see that many of the states with independent scopes of practice are in the western and northwestern United States. These are absolutely the easiest states to start-up your own practice because you do not have to find and PAY a collaborating or supervising physician.
Q: What exactly does “physician supervision” mean?
States that do not allow independent practice by NP's and CRNA’s usually require some sort of physician collaboration or supervision.
Collaboration is typically demonstrating that you are able to work with a physician and consult them in the event that you have a complicated case which you feel could benefit from a physician consult. Some states require a collaboration agreement with a physician to be writing, other states do not have this requirement.
Physician Supervision is the strictest of the requirements from which a NP or CRNA can work. It typically requires that a physician signs a protocol with you and the protocol outlines the scope of services that you can provide under that protocol. So essentially, you're being "supervised" by the protocol that is created with the physician. Some states also require a supervising physician to be physically present (this typically only applied to anesthesia). Some states also require the physician to do a certain number of chart reviews, so you want to look into that. It is typically outlined in either your nurse practice act or in the board of medicine regulations.
Q: How do I find the requirements for my state?
To find the detailed information on what you need to do to in order to remain within your scope of practice, you actually need to go to your Board of Nursing website and download the Nurse Practice Act.
Most Board of Nursing websites are absolutely horrendous and they make it incredibly difficult to find the information that you're looking for. I've searched some states like Tennessee and it will literally take you a couple of hours to figure out where to find the Nurse Practice Act because they do not make it easy! Other state websites like New Mexico make it very easy to find and download the Nurse Practice Act.
Once you find your Nurse Practice Act, start reading through it word-for-word. Many start by defining some of the terms that are used in the document. They'll always define every term used. Look for the word “collaboration.” For example, in New Mexico, collaboration is required for Nurse Anesthetists, but it not required for Nurse Practitioners.
To meet the collaboration rules, you'd have to read the definition from your state’s Nurse Practice Act. Make sure that the collaboration that you're claiming meets this definition.
Hint: A quick way to find a word on any page is to hit Control + F on a PC or Command + F on a Mac. This will bring up a search bar where you can type any word you are looking for, and it will find every instance of that word on the page you are viewing.
Next, search the document for your license type to see the scope of practice you’ll be allowed to use. So, for example, if you search for “certified nurse practitioner”, the Nurse Practice Act will list out what the qualifications of a certified nurse practitioner are, the practice requirements, examination requirements and licensing details. This is the information you need to look through to determine what a nursing professional with a specific license type is allowed to do in your state.
Ideally, you will want to see that you can practice independently and make decisions regarding the healthcare needs of the individual. This is the most important wording that you want to see. If you are looking to see if you can practice independently, the words “independent practice” and “independently” need to be in your scope of practice. In most cases it's very clearly stated. If it doesn't say it in that way, then you're going to have to do even more digging through the language in there to see if there's any sort of requirement for physician involvement. If the wording seems grey then you will need to consult with an attorney.
In your Nurse Practice Act, a lot of times there will be information on how to legally prescribe controlled substances and also which schedule of controlled substances you're allowed to prescribe. Some states talk about a "formulary" and some states have set up a specific board to create a formulary (essentially just a list of medications that are allowed to be prescribe).
If there's one of those in your state, you want to take a look at it and make sure that when you're running your practice that the medications you prescribe are authorized on that formulary. Some states, however, don't have a formulary.
For other Advanced Practice Nurses and for Nurse Anesthetists, it's going to be the exact same process, just search for your title instead.
Q: Can I practice independently if my state is “Opt-Out?”
One really common misconception for nurse anesthetists is that they think that because a state is an “opt-out” state means that they're allowed to practice independently. I'm here to tell you, 100 percent, that is not what that means whatsoever.
Your Nurse Practice Act is the only thing that can tell you if you're allowed to practice independently. What is an “opt-out” state? It is a state whose governor has declared that government insurance will reimburse a CRNA for services provided without being required to be supervised a by a physician. And so just because you're able to get reimbursed without physician supervision does not mean you're allowed to practice without physician supervision. What tells you if you can practice without physician supervision is your Nurse Practice Act. Period. Do not make the mistake of assuming that because you are an "opt-out" state that you can practice independently.
I hope that helps to explain a little bit about how to look into the rules regarding how to start a ketamine clinic, a practice or any sort of healthcare business. The answer in every single state is going to be yes, you can start a clinic, but you just need to make sure you follow the rules in your state.
If you are a Nurse Practitioner or a Nurse Anesthetist, you can start a ketamine practice. You just have to understand the rules on how to structure your business. After you have thoroughly studied the regulations and hopefully consulted an attorney, you just need to structure the operation of your clinic so that it remains within the rules outlined for your scope of your practice and the scope of practice of those who will be working for you.
If you have to collaborate with a physician then you would want to be able to document that you collaborated with the physician. It's that simple. If you had to have supervision and then you want to make sure that you follow the rules that are required for the supervision.
You can still own a clinic, you can still be a healthcare entrepreneur. You just have to follow the rules that are written in your state.
If you guys have any other questions, feel free to let me know. I love answering these type of questions! I love helping healthcare entrepreneurs start their own businesses.
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