Finding a Collaborating Physician in Missouri
The regulatory landscape for Nurse Practitioners (NPs) can be difficult to understand. However, Zivian was created to handle the challenges of compliance so that you can focus on providing care. If you are an NP trying to find a collaborating physician in Missouri, we’ve got you covered.
The state of Missouri requires nurse practitioners to collaborate with a physician. Missouri’s regulatory structure is Restricted Practice Authority.
In this post, we break down state regulations and key considerations for Missouri NPs to establish a compliant collaboration with a physician.
Note: State regulations and requirements are subject to change. Always check with your state medical or nursing board to confirm the most up-to-date information.
What is the Practice Environment for NPs in Missouri?
In which category does the state fall: NP independent practice, transition to independence, or collaboration required?
Nurse practitioners are required to have a collaborating physician.
Delegation Authority and Process
Is an agreement required?
Yes, a collaboration agreement is required.
What form of agreement is required and what are the requirements for the substance of the agreement?
Missouri has very specific rules regarding the required components of a collaboration agreement. Contact us today to learn more!
Where must the agreement be stored?
There is no requirement as to where to store the agreement.
However, the collaborative practice arrangement and any subsequent notice of termination of the collaborative practice arrangement must be in writing and maintained by the collaborating professionals for a minimum of 8 years after termination of the collaborative practice arrangement.
Does the agreement need to be filed with the state?
There is no requirement.
Are there requirements to file the agreement after the initial filing (e.g., for updates or on a specified frequency)?
There is no requirement.
Who must sign the agreement?
The nurse practitioner and the collaborating physician must sign the agreement.
How often must the agreement be reviewed / reauthorized?
The collaborative practice arrangement must be reviewed at least annually and revised as needed by the collaborating physician and collaborating APRN. Documentation of the annual review must be maintained as part of the collaborative practice arrangement.
What are the qualifications for the collaborating provider (licensure, same scope, active practice in state, etc.)?
No explicit requirements are stated other than the collaborating physician must be licensed in Missouri.
For prescribing purposes, there is an explicit requirement that “the methods of treatment and the authority to administer, dispense, or prescribe drugs delegated in a collaborative practice arrangement between a collaborating physician and collaborating APRN shall be within the scope of practice of each professional and shall be consistent with each professional's skill, training, education, competence, licensure, and/or certification.”
What are the qualifications for the NP?
Nurse practitioner qualifications can be found in the Missouri Code of State Regulations here (20 CSR 2200-4.100).
Is an alternate collaborating physician required?
There is no requirement.
Collaboration Requirements
Are there ratios / limits on the number of NPs that a collaborator may supervise or enter into collaboration agreements?
A collaborating physician mustnot enter into a collaborative practice arrangement with more than six full-time equivalent APRNs, full-time equivalent licensed physician assistants, or full-time equivalent assistant physicians, or any combination thereof.
Is there an express requirement to review a certain number / percentage of charts?
Every 14 days, nurse practitioners must submit a minimum of ten percent (10%) of the charts documenting their delivery of health care services for review by the collaborating physician, or any other physician designated in the collaborative practice arrangement. In addition, the collaborating physician must review a minimum of 20% of the charts in which the NP prescribes controlled substances every 14 days. The controlled substance charts may be counted in the number of charts reviewed in the general pool of chart review.
The collaborating physician must produce evidence of the chart review upon request of the Missouri State Board of Registration for the Healing Arts.
This subsection shall not apply during the time the collaborating physician and collaborating NP are practicing with the physician continually present.
Is there a requirement to meet and, if so, how often?
There is no requirement.
Are there proximity requirements (e.g., between the NP/collaborator or practice site)?
The collaborating physician must not be so geographically distanced from the collaborating NP as to create an impediment to effective collaboration in the delivery of health care services or the adequate review of those services.
The following shall apply in the use of a collaborative practice arrangement by an APRN who provides health care services that include the diagnosis and initiation of treatment for acutely or chronically ill or injured persons:
No mileage limitation applies if the NP is providing services utilizing telehealth in the care of the patient and if the services are provided in a rural area of need. A “rural area of need” means any rural area of MO which is located in a health professional shortage area, which is an area designated by the Secretary of Health and Human Services. A list of health professional shortage areas can be found here.
If the APRN is not providing the services outlined above, the collaborating physician and collaborating NP must practice within seventy-five (75) miles by road of one another; and
Pursuant to Improved Access to Treatment for Opioid Addictions Act, an NP collaborating with a physician who is waiver-certified for the use of buprenorphine may participate in the "Improved Access to Treatment for Opioid Addictions Program" (IATOAP) in any area of the state and provide all services and functions of an NP. A remote collaborating physician working with an on-site NP shall be considered on-site for the purposes of IATOAP.
The collaborative practice arrangement may allow for geographic proximity to be waived when the arrangement outlines the use of telehealth.
More details on Missouri collaborative practice proximity requirements can be found here (20 CSR 2200-4.200).
Are there location-specific requirements (e.g., that collaborator must go to practice site at some frequency)?
An NP who wants to enter into a collaborative practice arrangement at a location where their collaborating physician is not continuously present shall practice together at the same location for at least one (1) month before the NP can practice at a location where the physician is not present. It is the responsibility of the collaborating physician to determine and document the completion of the same location practice.
This does not apply to collaborative arrangements of providers of population-based public health services as defined by 20 CSR 2150-5.100.
This does not apply to collaborative practice arrangements between a primary care physician and a primary care NP or a behavioral health physician and a behavioral health NP, where the collaborating physician is new to a patient population to which the NP is familiar.
More information on location-specific requirements can be found here (20 CSR 2200-4.200).
Is remote supervision allowed/are there limitations on remote supervision?
The collaborating physician, or other physician designated in the collaborative practice arrangement, shall be immediately available for consultation to the collaborating NP at all times, either personally or via telecommunications.
Additional Filing Requirements
Outside of filing the collaboration agreement, must the physician and/or NP file any separate forms?
Within thirty (30) days of any change and with each physician's license renewal, the collaborating physician must advise the Missouri State Board of Registration for the Healing Arts whether he/she is engaged in any collaborative practice agreement, including collaborative practice agreements delegating the authority to prescribe controlled substances, and also report to the board the name of each licensed NP with whom he/she has entered into such agreement. A change includes, but is not limited to, resignation or termination of the NP, change in practice locations, and addition of new collaborating professionals.
Prescription Requirements and Controlled Substance Prescribing
What are the prescription requirements?
Prescription requirements are outlined here (20 CSR 2200-4.200, pg. 14).
What are the requirements for controlled substance prescribing?
The board of nursing may grant a certificate of controlled substance prescriptive authority to an NP who:
Submits proof of successful completion of an advanced pharmacology course that shall include preceptorial experience in the prescription of drugs, medicines and therapeutic devices; and
Provides documentation of a minimum of 300 clock hours preceptorial experience in the prescription of drugs, medicines, and therapeutic devices with a qualified preceptor; and
Provides evidence of a minimum of 1000 hours of practice in an APRN category prior to application for a certificate of prescriptive authority. The 1000 hours shall not include clinical hours obtained in the advanced practice nursing education program. The 1000 hours of practice in an advanced practice nursing category may include transmitting a prescription order orally or telephonically or to an inpatient medical record from protocols developed in collaboration with and signed by a licensed physician; and
Has a controlled substance prescribing authority delegated in the collaborative practice arrangement under section 334.104 with a physician who has an unrestricted federal Drug Enforcement Administration registration number and who is actively engaged in a practice comparable in scope, specialty, or expertise to that of the advanced practice registered nurse.
For more information, please visit the Missouri Division of Professional Registration’s website and see instructions titled, “State of Missouri Advanced Practice Registered Nurse: General Instructions for Controlled Substance Prescriptive Authority.”
Find a Collaborating Physician in Missouri with Zivian Health
Zivian handles all the challenges of compliance so that you can stay focused on providing great patient care.
If you are in need of a collaborating physician, contact us today!
Sources
§ 334.104 R.S.Mo.
§ 334.108 R.S.Mo.
§ 335.019 R.S.Mo.
§ 335.175 R.S.Mo.
§ 630.875 R.S.Mo.
20 CSR 2200-4.200
20 CSR 2200-4.100
