1. Presented by: Julie E. Chicoine, Senior Vice President and General Counsel September 9, 2016 Advanced Practice Professionals Who, What, Where, When & How

2. Advanced Practice Professionals (APP’s) Who Are They?  Advanced Practice Registered Nurse (APRN) –Certified Nurse Practitioner (CNP) –Clinical Nurse Specialist (CNS) –Certified Registered Nurse Anesthetist (CRNA) –Certified Nurse Midwife (CNM)  Physician Assistant 2

3. Certified Nurse Practitioner CNP Means a registered nurse who has completed specific advanced practice of nursing education to provide preventative and primary care services, evaluate and promote patient wellness https://www.ncsbn.org/aprn.htm Majority of states require supervising physician Licensed by State Board of Nursing (Advanced Practice Nursing) 3

4. Clinical Nurse Specialist CNS Means a registered nurse who has completed advanced practice of nursing education to provide and manage the care of individuals and groups with complex health problems and provide health care services that promote, improve and manage health illness states/disease management https://www.ncsbn.org/aprn.htm Majority of states require supervising physician Licensed by State Board of Nursing (Advanced Practice Nursing) 4

5. Certified Registered Nurse Anesthetist  CRNA  Means an advanced practice nurse who provides full spectrum of anesthesia services and anesthesia related care in a variety of patient care settings including but not limited to hospital surgical suites  Licensed by Board of Nursing (Advance Practice Nursing) 5

6. Certified Nurse Midwife  CNM –Registered Nurse with graduate education specializing in primary and patient care services for child bearing women. –Care often focuses on normal pre and post natal patient population –Licensed by Board of Nursing (Advanced Practice Nursing) –Not to be confused with “lay midwife” 6

7. Physician Assistant PA Means a clinician who has completed an advanced level of education and is licensed to practice within a supervising physician’s normal course of practice and expertise, including the diagnosis and management of acute and chronic conditions All states require physician supervision Licensed by Board of Medicine 7

8. What Can They Do?  The scope of clinical practice is established by state law which varies from state to state  Texas – defers to national accrediting bodies, formal education and supervising physician 8

9. Certifying Bodies - Advanced Practice Nurse American Academy of Nurse Practitioners American Nurses Credentialing Center Subsidiary of American Nurses Association National Association of Pediatric Nurse Practitioners Gerontological Advanced Practice Nurses Association American Association of Nurse Anesthetists American College of Nurse Midwives National Association of Clinical Nurse Specialists 9

10. Certifying Bodies – Physician Assistant American Academy of Physician Assistants (AAPA) National Commission on Certification of Physician Assistants 10

11. Advanced Practice Nursing – Texas Scope of practice is consistent with advanced education, which must be formal – not continuing education Texas defers to expertise of APRN professional societies for educational standards Texas requires professional certification from nationally recognized accrediting body for advance role and specialty. 11

12. Physician Assistant – Texas  Must be licensed by Texas Board of Medicine  Must practice under physician supervision  If prescribing drugs, must have a Prescriptive Delegation Agreement in place with supervising physician 12

13. “Dr.”???  Healing Arts Identification Act – Texas –APRN’s must specify their education.  Jane Doe, RN, DNP  Jane Doe, RN, DNS  Jane Doe, RN, PhD –Must clarify their status as clinician and not physician 13

14. How Are APP Services Billed?  Medicare – Part A or Part B depending  Medicaid – Provider enrollment  Commercial Payers – Contract negotiations for coverage 14

15. General Reimbursement Principle 15 Coverage is limited to services that: The APP is legally authorized to perform within the state, and Are not otherwise statutorily excluded

16. Questions 16