Photo Credit: Peshkov

All doctors need some coverage help, but to avoid legal issues, it’s important to be clear and know the practices of the groups you partner with.

Q: I am in solo practice, so I participate in a coverage group with several other pediatricians that have privileges at my hospital. Although I don’t know them closely, I was given copies of their CVs when I joined (and had to submit mine), and I know that they have good reputations. I was recently contacted by the person who was covering to tell me that he was admitting a baby with likely hypertrophic pyloric stenosis to my service and had called a surgical consult. He introduced himself as “Dr. (his name)” and mentioned that he had just joined the practice of someone else in the coverage group. However, when I reviewed the chart, I saw that he is a Doctor of Nursing Practice, so a nurse. When I joined this coverage group, I did not agree to be covered by nurses and certainly did not agree to supervise their work. How should I handle this?

A: Let’s start by separating out the issue of supervision. Supervision of a mid-level practitioner is a formal matter, governed by state laws and with billing consequences that have specific criteria as to the level of payment. This situation is no different than if another doctor, while covering, touched base with you and you either agreed or disagreed with their actions. It is not supervision solely because the other practitioner is a nurse.

The issue here is that the practice he joined cannot add him to the roster of covering practitioners without giving notice to the other participants and receiving their approval. A practice can have its own level of risk tolerance and can establish its own internal criteria for staff membership. Your state may also allow advanced practice nurses to function independently, but the coverage group is an entity with its own contractual requirements that you rely on when entrusting your patients to it. As in a referral situation, knowing the qualifications of the other participants is what makes that entrustment non-negligent and acceptable under your fiduciary responsibilities to the patients who are in no position to choose who covers them when you are not working.

Even if that individual were a doctor, inclusion in the coverage “bench” would therefore not extend to them unless they met the criteria. This is why CVs are requested and proffered when there is a new entrant to the group, a step that was lacking here.

The fact that any new practitioner would be providing coverage through the group should have been related to all members with enough notice for them to accept or reject the change, and the specific point that this individual is a nurse should have been made clear to the rest of the group members. At this point, the doctor who added their nurse associate to the schedule should inform their group colleagues, who can then decide whether they will accept this change, and you should contact them to insist that they do so.

There is also a malpractice insurance issue here. Your policy is currently rated for the activities that you told the company that you engage in. You practice medicine on your own in your office as your predominant work, but you also cover the patients of other doctors who are in other practices and those doctors, who have known qualifications, cover your patients. However, just as if you had personally hired an advanced practice nurse to work in your own office, the insurer must know that the care of your patients may now come from a non-physician, allowing it to either decline coverage or to set its rates accordingly.

That this mid-level practitioner is himself covered under his office’s policy is irrelevant to this matter. That insurance covers him for what he does, but you need coverage for what you do—in this case, entrusting your patients to care that may come from a non-physician but is delivered under your aegis as a legal matter because you selected the source of the coverage.

The insurance issue is a critical point. If there was a lawsuit in a case in which this coverage was a factor, then your carrier could now disclaim from indemnifying you because of what would be characterized as a material misrepresentation of what they were insuring, a breach of your contract with them. You should therefore inform the company of this change if you will be staying with the coverage group.