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Hi everyone,

I've been a practicing PA-C in Florida for nearly 4 years now. I worked for 3 years in Peds ICU and am now 6 months in at a private practice cardiology office (no non-compete). Just today I was approached by my best friend's father who is the medical director at a local SNF. He's looking for a PA or NP to help him with rounds occasionally and cover for him while he's out of town...starting next week. I'm meeting with him tomorrow to talk over some details but I need to come into the conversation prepared. He's worked with an NP before but she transitioned to a hospitalist position with a non-compete clause. And he's made it very clear that I can say no and he'll still think the world of me (like I said...bestie's dad, he's a good guy). He's got a system set up that will get by while he's gone, just not ideal.

I must confess that so far, I have had a lot of the "background work" taken care of for me and I've only ever had to worry about the medicine and charting accordingly. In the ICU, I was a hospital employee and did zero billing. In my current practice we have a team of billers and all I have to do is provide ICD-10 codes and check-off the level of visit. I've always known exactly who my supervising physicians were and have never had them be further away than across the street, in the other hospital building. 

He was asking whether I could see patients independently and bill for it. I replied yes because my understanding is that a supervising physician need only be "readily available" if needed. His partner will be in town and available by phone and in person if need be. This other MD will be covering true emergencies because they'll be admitted under his practice's service but needs someone else (me?) to round on the patients that have non-emergent, stay-at-the-SNF but still-need-to-be-seen illnesses arise. 

I'm confused, however, because I've never had to consider these things. Whether I'm "supervised" sufficiently for legal standards. How to bill for my services, especially as I'm reading about 1099 "contractor" positions and how to handle billing. What the what? I also know next to nothing about the Medicare requirements for care in a SNF.

I'm also a little nervous because I haven't done primary care since school. I consider myself a smart person and I can definitely reference uptodate with the rest of them but I know that wisdom sometimes includes recognizing your limitations.  The idea of titrating someones diabetes meds gives me the willies...because I've never done it. (ICU background: all I've ever ordered was an insulin gtt protocol or basic SSI protocol followed by a consult to endocrine for the rest). Friend's dad will be available by phone but I also don't want to bug him on his vacation unless I have to and I've never met the other MD.

Can I do this? Should I do this? If I do this, what do I need to be aware of, legally? HELP!

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Well... that is a bit of a complicated question. Supervision rules vary from state to state and sometimes vary in different places in a state (Rural vs Urban for instance).

On it's face it seems you would be meeting the supervision requirements. Here is the better question....is it a good idea for you to cover patients in a field you aren't comfortable with, with remote supervision and occasional on site supervision from a doc you don't know? It seems like a lot of variables that could spell a bad outcome.

Your mileage may vary.

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Thank you for your reply! I think you've confirmed my main hesitation. I'm meeting with him in a couple of hours and I think I'll tell him no for this week, because honestly it does feel unsafe. We can look to the future for ways I can help him but only after I've gotten to round with him in person and get some basic training for a bit.

Thanks!

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You are absolutely trained well enough to do this job.  Will there be a learning curve?  Hell yeah, and you will have to climb it by yourself because of limited supervision, but you certainly can do that, especially if this is a low-census, take-your-time position.

Think about it this way...a NP did it.

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I would probably not do it as if you only ordered SSI or insulin ggt per a protocol then you (most likely) don't have tools/knowledge to be changing/managing patients with diabetes let alone all the other stuff you do in primary care. I will find my other post about what FM medicine provider see on a weekly/monthly basis and edit my post so you can see what I see on a daily basis. These are the most commons and the list if no exhaustive so you would have to be at least familiar with most on the stuff on the list (and familiar to me is understand the patho/pharm/pathology/treatment/work up/management/when to refer/etc.). I do not think having 3 years of PEDs ICU and 6 months of cardiology has prepared to you work ("independent") at a PRN done with very complicated/comorbid patients that most likely have a list of meds 2 pages long...If you were going to do it full time you would be find as you would have mentorship, but with a PRN job you will have zero guidance with every patient meaning it will take you a very long time to learn "FM/IM" at a PRN SNF job. I have been in rural family medicine x 4 years and now just feeling comfortable with the craziness I deal with on a daily basis. 

I will tell you what I see on a weekly basis: HTN, DMI/DMII, hyperlipidemia, CHF, A-fib, AAA, carotid stenosis, migraines, depression, bipolar, GAD, SLE, RA, OA, chronic pain in every joint possible, gout, fibro, uti, renal caculi, thyroidism, obesity, tobacco abuse, vertigo, bronchitis, PNA, sinusitis, allergic rhinitis, epistaxis, obstructive and restrictive pulm disease, AOM/swimmers ear, all kinds of DERM (AKs, SKs, SCC, BCC, vitiligo, tinea (all of them), exanthematous rashes, dermatitis), wound care (DM ulcers, arterial/venous ulcers), cerumen impaction, lymes, rocky mountian spotted fever, ehrlichiosis, tularemia, OSA, ingrown toenails, felon, paronychias, herpes zoster, DVTs, fractures, strains/sprains, acl/pcl/mcl/lcl/meniscus tears, PCOS, genetic testing, allergy testing, dehydration, chest pains, afib with rvr, stemi/nonstemi, a-flutter, hypoglycemia, laceration repair, suicidal ideations, IDA, B12/vit d deficiency, rectal bleeding, hemorrhoids, peptic/gastric ulcers, UC/crohn's disease, dental abscesses/thrush. Thats what I have seen this month plus I know I left some out. Read uptodate. Ask questions a lot. 

P.S. I did not even put down the procedures I do either. Good luck!"

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On Sunday, April 22, 2018 at 9:39 AM, Boatswain2PA said:

You are absolutely trained well enough to do this job.  Will there be a learning curve?  Hell yeah, and you will have to climb it by yourself because of limited supervision, but you certainly can do that, especially if this is a low-census, take-your-time position.

Think about it this way...a NP did it.

Best post on the internet today.

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