Jun 15 2016

Requirements for Supervision of a Physician Assistant and Physician Co-Signing of Charts

By Jennifer A. Rymarski, Partner, and Michael R. Lavoie, Law Clerk

Massachusetts General Laws Chapter 112, §§ 9C–9K, define a “[p]hysician assistant” to mean a person who meets certain registration requirements and “who may provide medical services appropriate to his or her training, experience and skills under the supervision of a registered physician.” See also, 263 CMR § 2.03.

A physician assistant (“PA”) works with an amount of independence somewhere between a registered nurse and a resident or hospital fellow. PA’s require supervision by a physician. G.L. c. 112, s. 9E(1) authorizes a PA to “perform medical services when such services are rendered under the supervision of a registered physician,” and requires such “supervision” to be “continuous.”

The regulations authorize a physician assistant to “serve the patients of his/her supervising licensed physician,” 263 CMR § 5.03, and “under the supervision of a licensed physician, [to] perform any and all services which are (a) Within the competence of the physician assistant in question, as determined by the supervising physician's assessment . . . and (b) Within the scope of services for which the supervising physician can provide adequate supervision to ensure that accepted standards of medical practice are followed.” 263 CMR § 5.04(1).

A physician assistant’s authorized area of work was required to be “consistent with his or her supervising physician's scope of expertise and responsibility and the level of authority and responsibility delegated to him or her by the supervising physician.” 263 CMR § 5.04(2). The physician assistant may not “supplant a licensed physician as the principal medical decision maker.” 263 CMR § 5.05(2).

The supervising physician must “afford supervision adequate to ensure . . . [t]he physician assistant practices medicine in accordance with accepted standards of medical practice,” and when the supervising physician “is unable or unavailable to be the principal medical decision-maker, another licensed physician must be designated to assume temporary supervisory responsibilities with respect to the physician assistant.” 263 CMR §§ 5.05(4)(a), (4)(g). Physician assistants are not authorized to bill separately for their services because the regulations declare “[t]he services of the physician assistant are the services of his or her supervising physician.” 263 CMR § 5.06. Finally, and perhaps most importantly, the regulations make clear that “[w]here a physician assistant is employed by a physician or group of physicians, the employing physician or physicians shall remain legally responsible for the acts or omissions of said physician assistant at all times . . . .” 263 CMR § 5.09(1).

Regulations concerning the practice and supervision of PAs are written broadly. In Massachusetts, there is no legal requirement that a supervising physician sign/co-sign every PA or MLP chart. However, the co-signing of charts may be an internal requirement of the employer, medical practice, or a third-party payer. Although co-signing is not required, from a risk management perspective and financial perspective, the better course appears to be that employers should establish collaboration policies to provide oversight and assurance that the PA is providing appropriate care, and to ensure that the cost of such care is able to be recouped.

Based on the regulations, supervising physicians within Massachusetts are liable for the acts or omissions of their PAs, assuming the PAs are the employees of the physician group. It is a form of vicarious liability. In this respect then, a physician’s liability is neither expanded nor diminished by the co-signing of chart. The absence of a physician’s signature may, on one hand, provide some limited protection for the physician in that the supervising physician’s identity may not be readily known; however, given the requirements that a PA be supervised and the vicarious liability imposed upon a physician for a PA working under his or her supervision, the co-signing may be beneficial to ensure the quality and appropriateness of care. This interest is weighted, however, against the work-flow and/or logistical perspective of the business of medicine, in that mandatory co-signatures may diminish the overall quality, efficiency, and expeditious rendering of care. That is, a physician may have less time to devote to those patients requiring a higher level of care, if the physician is required to evaluate, oversee and sign every single chart or routine order of a PA.

Because the supervising physician will be liable for a PA’s acts or omissions regardless of whether he or she signs off on every chart/order, the recommended best practice is to have policy wherein charts are reviewed on a periodic or systematic basis, or if certain criteria exist with respect to the patient. Further, the policy should track the regulations with respect to the assignment of a supervising physician, or in his or her stead, a temporary supervisor.

These policies can be part of an employment contract with the PA or part of an overall office policy. Caution must be used, however, in crafting these policies, as a very detailed policy may expose the practice to liability if the policy is not followed precisely. On the other hand, not having any policy at all, may suggest a lack of oversight on the part of a physician.

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