Botox injections

[Guest Paula]

My IM practice had an NP who worked with the neurologist to perform Botox injections for patients with headaches.  The NP has left our practice for another job and I just found out yesterday that she delegated botox injections to her MA.  I am unsure if they both did injections at the same time together and will be asking the MA how that worked.

 

Is it ok to delegate this to an MA to do alone?  I was surprised that an MA was delegated the responsibility, even if the NP was present at the time.  Is it billable for an MA to do the injections? 

 

I am naive as to the side effects, risk/benefit to the procedure and how simple/complicated the injections are.

 

Would it be a good idea for me to approach the neurologist to get the training to do the injections?  I am getting the NPs patients now in her absence and I don't do the injections.  The clinic is advertising for another NP (not a PA) to fill her position.  She also did general practice IM as well...she was PT in the neurology department and the neurologist delegated the headache patients to her after training and determining which patients were good candidates for the injections.

 

I'm wondering if I should expand my scope and offer myself for training.  Currently I work FP/IM.

 

Thanks for all your input. 

 

 

[jdenning]

I work in a neurology group and only the neurologist does Botox.  Period.  I'm surprised the neurologist would be ok with an MA doing it.  I would check state practice act whether that procedure is allowed to be done by an MA.   

[LKPAC]

Short answer: NO!  It is not OK for an MA to perform botox injections.  I can just see those headlines when something goes wrong...

[Guest Paula]

I will check the practice act for MAs. They do many other injections such as immunizations. The RNs do some injection the MAs can't which I think is setting up IV antibiotics and some of the travel medicine injections. I'll ask the RNs tomorrow.

[Guest Paula]

I'm hoping jmj will see this post and respond.

[RuralER/Ortho]

I may be wrong, but I believe the botox injections are given as trigger point type injections and specific techniques/locations. These are not standard IM (deltoid, glute) type injections. An MA should definitely not be giving these injections.

[LT_Oneal_PAC]

While the Botox injections for migraines I have seen aren't terribly difficult, I would not let an MA perform them. They shouldn't be injecting near any major vessels or nerves, but they could cause spread and temporarily paralyze an eye or something else causing the patient distress. That kind of responsibility should be placed on a provider IMO. I wouldn't have any problem doing them myself with a some training, mainly on who would be a good candidate.

[rev ronin]

I may be wrong, but I believe the botox injections are given as trigger point type injections and specific techniques/locations. These are not standard IM (deltoid, glute) type injections. An MA should definitely not be giving these injections.

Indeed.  I ended up having to personally give Rabies Immunoglobulin to a patient after a suspected bat saliva exposure, because infiltrating around a wound is "not a nursing skill," even though nursing staff gave just about everything else except for joint injections at that practice group...

[jmj11]

I have done Botox for migraine since about 1999. I can say with very strong confidence that a MA should never be doing the injections. Allergan would trun over in their grave . . . if they were dead.  This is something they fear is that non qualified providers would be doing it. Does it violate the law? It is not clear as some MAs, depending on their license, can do "IM" inejctions and Botox is an IM injection. However, this is NOT the standard of care and if there was a complication, it would be very hard to defend in court.

 

I will say also with confidence (being on a listserve of most headache practices in the country) that doing Botox, while lurcerative at one point, has become ,at best, a revenue netural endeavor.  I would never, ever get into the business of buying Botox again.  At $1200 a pop (last year I bought $150,000 of Botox) about 1 out of 10 is never paid, despite having a prior authorization. A prior authorzation does not guarentee payment and the insurance company will screw you if they can. So now we use a speciality pharmacy and I write a Rx for Botox and let the patient "get it" (it is mailed to us) like any prescription and we don't pay for it upfront. 

 

So, while an insurance company will pay you $98-$180 to do the procedure, they will also use about 10 hours of staff time per Botox patient for prior authorization, fighting to get them to pay and etc.  We have had two recent Botox treatments that took three years to get payment and probably 60 hours of effort by my biller to get thay payment, so a net loss of several hundred dollars. There was nothing wrong with the claim, but both insurance companies kept "loosing" the claim, the chart notes and even their own prior authorization.

 

The only reason that I still do it is that patients want it and it actually does help some patients to get better.

[Guest Paula]

Ok, thanks all.  That being said, I think I will skip the idea of getting trained on doing Botox.  I will have a discussion with the RN that I trust the most in my department.  I think she would have a coronary if she knew (maybe she does know)!  It will be an interesting discussion for me to find out what the protocol was for the NP and her MA.