Clinicians Business Tip: Collaborating Physicians: The Basics, Part 1

Collaborating Physicans www.npbusiness.orgIt’s 2013 2020 and still, more than half the states require Nurse Practitioners and other advanced practice nurses (APN’s) to have a formal collaborative (and in some states supervisory) relationship with a physician. While the Future of Nursing Report recommends removing barriers to full practice, it’s likely to be slow going. Thus, finding and working with one or more collaborating physicians is a reality for many of us. However, the “political” climate and regulations in many states make it challenging to do so.

In a state where NPs must have collaboration in order to practice in either an employed or self-employed situation, the lack of a collaborator impedes the NPs ability to provide patient care and has forced the closure of more than one NP owned practice.  Collaboration is not only short-sighted; it’s also costly and reduces a patient’s access to care.

Because of these challenges, NPs have many questions regarding collaborating physicians (CP) including:

·      When do I need a collaborating physician?

·      What are they responsible for?

·      How can I find a collaborating physician?

·      Do I need to pay for collaboration and if so, how much?

·      Do I have to pay for their malpractice insurance?

·      Should I have a written contract or agreement?

Let’s take a look at each of these questions:

Do I need a collaborating physician?  In order to answer this question, it’s imperative that you read and thoroughly understand what is required in your state. You will need to look at rules and regulations from the board of nursing, the board of medicine, and any business or corporate laws regarding collaboration or hiring of physicians.

Often, I receive a question from someone who asks if they really need a CP if they are not prescribing, or if they are functioning as a health coach vs NP, or something similar. The answer is in your practice act and with your board. Some practice acts will delineate specific tasks and functions that require collaboration, others will be more generic. This is why it is imperative that you read and understand exactly what it required of you.

But don’t stop there. If you are required to have a CP, then I recommend you also read the BOM practice act to understand the rules and regulations regarding physician collaboration with NPs and other APN’s. You’ll want to be clear on what is expected of the physician and any restrictions that may be in place (chart sign-offs, distance, physical requirements in your practice space, the number of NPs that one can collaborate with, and the like).

 You’ll also want to take a look at any business/corporation restrictions that may be placed on physicians. In some cases, they cannot be hired by non-physicians and thus cannot be compensated in the form of cash.

What are they responsible for? Physicians are not always aware of what is required when they are approached by an NP regarding collaboration. Thus, it is your responsibility to find out and be able to communicate this information clearly. You will not be able to move forward this obtaining a CP until you are both clear about the required responsibilities.

Some states require collaboration for all areas of practice and others for just parts of practice such as prescribing legend medications and/or controlled substances. You may be required to have written protocols, reference textbooks, or just be required to reach out when necessary.

 Furthermore,  practice acts (both BOM and BON) may require any of the following:  physical presence in the practice X number of hours per month; a distance of X miles from the NP practice; X number of charts signed off each month/quarter;  face-to-face collaboration (in some cases Skype, Facetime or other video conferencing may be acceptable); other methods and time requirements for communication or even just “as needed” communication with the method (phone, email, etc) being documented.

 That’s it for this time. We will pick up with finding a collaborating physician,  paying the CP (as well as malpractice coverage) and agreements next time.

Looking for Part II?  
Collaborating Physicians: The Basics, Part 2

Tell us below, what your challenges are regarding collaboration. How has it affected your practice, your ability to provide patient care?


Barbara C Phillips, ARNP, FNP-BC, FAANP is a professional speaker, author, clinician, and business owner who provides business education, resources, and support to Nurse Practitioners, Physician Assistants and other Advance Practice Clinicians – both for the employed and self-employed clinician. Additional information about Ms. Phillips is available at ClinicianBusinessInstitute.

Article updated August 2020.

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  1. I just formed Elder Care Concepts LLC in January. I began reaching out to physicians last October. I didn’t form the LLC until I had a colalborative physician. It was a lengthy and frustrating process. Most of the physicians I contacted by letter did not respond, either positively or negatively. My collaborative physician responded because we both are interested in caring for the population on the south side of Chicago.

  2. I moved to KY after a physician contacted me to purchase his practice. It was a great deal (for a month or so). Once I was established he changed our agreement, his collaboration was part of the purchase agreement. He informed me he needed $1000 a month or he would cease our prescriptive collaboration. Our relationship deteriorated and he ceased to collaborate.
    It had to be a Family Practice physician, and none of my competitors in town would sign. (Easy way to stop competition) I eventually found another physician across the state willing to sign for half price.
    By that time the damage was done, I was out of business soon after.

  3. I recently closed my practice. It is very difficult to have your own practice in the state of California. I had difficulty getting medi-coal to accepting me as a provider. I leased the office space from my collaborating physician when he wasn’t there. I paid him a percentage of my receivables for reimbursement of his staff, lights, equipment use, etc. Unfortunately, he felt he had a right to instruct me to see x amount of patients per day and x number of days per week. Between the reimbursement issues and push from my CP, I felt the practice was not for me. Was a learning experience. Hope the law soon changes.

  4. TN KY and NC require collaboration and as a DNP in a solo practice I have to pay an MD monthly to run my business. Thus far I have been fortunate in finding decent people to work with but have had to explain a few times why my doctorate is not honored by the state, the insurance companies for equal reimbursement, or in one case by a local physician who recommended a patient see a physician instead of just a nurse. I attempted to post how-to info on our state’s NA member board and was told I was not allowed to share what I pay a collaborator knowing some shell out thousands as they do not have any guidelines to assist them. I would move to a “friendly” state if it were possible but continue to grit my teeth in the face of such political ignorance, offering input every chance I get yet told over and over that the NP agenda is not ready for this change. I pay an MD because I must to practice my craft yet I cannot hire one unless I make her a partner. Cannot hire a PA LCSW or any other non nurse licensed healthcare professional for that matter. I had to form three corporations (expensive), so as not to appear as partnering with a non nurse. Fourteen years as an NP, eleven years of university education (with loans), and eight years of prior experience as an RN, yet not qualified for independent decision making despite doing just that every day. Frustrated? You bet.

  5. The CP is very frustrating and restrictive in Illinois. We are collecting data / information on the monthly amount, percent, etc that APN’s must pay physicians for the collaborative agreement. If anyone is willing to share, I would appreciate hearing from you. Some of the legislators I spoke with this session, we very surprised about us having to pay the collaborative physician. This issue needs to be public with the legislators who make the regulations that restrict our practice ultimately resulting in limiting patient access to health care. Looking forward to hearing from you.

  6. Information suggests Ilinois is not alone in experiencing the effects of restrictive policy and legislation. Not only does this impact the nursing profession, but also severely affects access to healthcare services to large segments of the population in all specialties. See articles below:

    Connecticut Nurses Association (2012). Request for consideration of scope of practice change. licensing_ and_investigations/_2013_scope_of_practice/ct_aprn_coalition_scope_of_practice

    Interestingly, 80% of the primary healthcare workforce is comprised of nurses (Hughes, 2006). This of course represents a sizable political consituency and voting block that if mobilized, could entirely “even the playing field” for the nursing profession and our patients.

    Hughes, F. (2006). Nurses at the forefront of innovation. International Nursing Review, 53(2), 94-101.Hyler, S. & Gangure, D. (2003). A review of the costs of telepsychiatry.

  7. I started a Women’s Health NP practice in Harlem NY in 2005. The physcian whoI wanted to collaborate with me insisted that I see Medicaid patients and not fee for service patients as I had planned (as the sole proprietor of my practice). I was unable to sustain the practice but had offers from other physcians. I have found that it is easier for someone who has no license or no extensive healthcare training to set up a business as a fee for service and see as well as “treat” clients then it is and was for me as 20 year NP and 30 yr RN.
    I however ,will not give up and will stay determined to offer my services to women. Looking for a GYN and/or Holistic NYS licensed physcian to collaborate my Women’s Health practice with in NYS.

  8. I have been working as a locums practitioner for about 2 years. I want to stay in Indiana, and have found a place to practice. I have not yet found a collaborative physician. This is always a sticking point. I wish I could have found a practice like this in Minnesota where I could practice independently. I currently have no idea where to start, and I am going to be needing to work soon. The patients and the money are there, but the physicians are hard to locate.

  9. Hi Tammy,

    Finding a CP is difficult at the best of time. As suggested start with who you know and work outward.
    Let me know how it goes!

    ~ Barbara

  10. Yes finding a collaborative physician in Indiana is very frustrating!! Wanting to open addiction clinic to help people but need a collaborative to oversee a PA to prescribe suboxone!! Reached out to several but no luck yet. CAN ANYONE HELP PLEASE!!

  11. It can be frustrating. You can try posting a job in something like Indeed. There are also several businesses now that will help find a collaborating physician – for a fee of course. it’s always best to have someone you have a professional relationship with, but it’s not always possible.

  12. I’m in PA. I am a Hospice and Palliative Care NP who collaborated with the Medical Director of Hospice and Palliative care. I also go into the community to see hospice patients, give orders to nurses, etc….when I am on call for patients of the physician I work with or if the patients physician is not available to order. Since patient is hospice I care for the patient when their doctor is not available and this was agreed upon by my collaborating physician. First question is if this is okay for me to order controlled substances, other orders for these patients since my collaborating physician is the medical director and my second question is can I clean the patients ears that is not a patient of my collaborating physician but is a hospice patient that is cared for in the community by the nurses I work with. The medical director is totally fine with me cleaning the patients ears and their doctor gave an order that I can clean the patients ears even though the patient is not directly mine but since I collaborate with the Medical Director, both of the physicians say it’s fine for me to care for the patient

  13. Of course, you’d need to look at what is appropriate in your state.

    Generally, when someone is in hospice, all the needs related to hospice have to be approved by the company providing the services. You cannot bill outside of hospice. If the issue is unrelated to the reason for being in hospice, you can bill for that service, using a modifier (for example Medicare). But for anything related to the reasons for hospice, you’d need to ask the facility if you want that service to be paid for. I hope I understood your question.

  14. Thank you for mentioning that rules and guidelines from the boards of nursing and medicine, as well as any corporate or business legislation regulating cooperation or the hiring of physicians, must be reviewed. My husband has opened a clinic and is looking for medical professionals to work with. I will advise him to work with a medical collaborator so that he is familiar with the guidelines.

  15. It's very frustrating and what makes it even worse, the various BON rules from state to state. If we could standardize the BON's rules for everything, that would make our lives as nurses much easier. Trying to navigate each state's requirements is so frustrating. Collaborating physicians (CPs) are nice, but in all honesty, mine (at my current job), does very little. I have met him once and I honestly don't believe he reviews my charts. I think someone else may. Perhaps NPs should be required to have one for a time, such as 5 years, and then be able to function independently. Most NPs I know feel like the CPs are just making money off of us and we get very little in return.

  16. I believe you are correct.

    This is the way I see it. NO ONE in healthcare works (or should work) in isolation of other healthcare providers. I have never had a collaborating physician, and yet it did not ever stop me from reaching out when I needed another opinion or did not know how to handle something specific. It could have been another NP or MD in the practice I worked in, or a specialist what I thought a patient may need to see. I’ve never had anyone refuse to speak with me or assist me. All providers reach out to each other.

    Our roll, all of our rolls, are to provide the best care we can to our patients. They are the priority.

    It is time for collaborating to be a thing of the past. However, it will not go away easily…there are factors beyond what is best for the patient at play.

    Thanks for your comment.

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