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Fam Pract Manag. 2002 Oct;9(9):67.

RHC protocols


Our rural health clinic (RHC) is in the process of becoming accredited, and we are trying to develop patient care protocols. Can you offer some tips for developing such protocols?

The Rural Health Clinics Act, PL95–210, requires RHCs to have guidelines in place for the medical management of their patients. These guidelines are often thought of as detailed treatment plans, which can seem daunting to develop given the wide array of patients and situations that need to be planned for. However, in most cases, the patient care protocols should be general guidelines, not “cookbook” templates. In a few cases, they may be very specific treatment guidelines, but this is the exception rather than the rule.

To make the process more manageable, many clinics have chosen to implement existing guidelines adapted to their unique situations and to the varied styles of their providers. For example, a clinic could follow the American College of Cardiology/American Heart Association guidelines for the evaluation and management of chronic heart failure, making modifications for local needs. Clinics could choose to develop their own standing orders for other clinical situations, such as pain management, migraines or chest pain.

However you develop them, your protocols must meet the following federal guidelines (42 CFR 491.9(b), summarized at They must be comprehensive (providing treatment plans for most common health problems), must specify which actions can be carried out by midlevel providers such as nurse practitioners and physician assistants and which procedures or situations require physician involvement, must describe the clinical situations that require consultation or referral, and must be compatible with applicable state laws.

Remember that your protocols will not only serve to meet the federal guidelines but will become your clinic’s standard of care, so develop them wisely. Depending on how you create them, these protocols could be a risk-management asset or liability for your practice.

Supervising an NP


I work for a hospital-owned, nonprofit clinic that has employed a nurse practitioner (NP). As the NP’s supervising physician, what medicolegal steps should I take to ensure that I am fulfilling my duties as her supervisor? Do I need to cosign all of her charts? Can she bill under her own name for private insurance companies? What if I disagree with her management plan and the patient has already left the clinic?

Much of what you are asking is controlled by state law. Most states have specific requirements under their Advanced Nurse Practice Acts regarding the extent of control the supervising physician must exercise (e.g., whether you must sign the NP’s notes). At a minimum, you should be sure your malpractice carrier knows you have taken on this responsibility.

Private insurance companies vary widely as to whether they allow direct NP billing, so check with your insurers. In addition, find out how the hospital that owns your practice handles NP billing, as their procedure may dictate your procedure. [For more information about billing for NPs’ services, see “The Ins and Outs of ‘Incident-To’ Reimbursement,” FPM, November/December 2001, page 23.]

You should have a written agreement in place that addresses when the NP and physician will interact regarding a patient. If the physician disagrees with an NP’s management plan, depending on what the nature of the disagreement entails, either the NP or the physician should request that the patient return or the drug prescription be changed.

Closed to new Medicare patients


I am in a relatively new practice that is becoming top heavy with geriatric patients. I would like to control this aspect of my practice by closing to new Medicare patients while continuing to remain open to other new patients. Is it lawful to close a practice to a particular payer type?

Yes, you may close your practice to new Medicare patients while remaining open to other new patients. Medicare is a voluntary program for physicians, so you are free to choose whether to provide services to new or established Medicare beneficiaries. The federal courts have upheld this principle on multiple occasions, including the case of Garelick v Sullivan. The court in Garelick noted, “All court decisions of which we are aware that have considered takings challenges by physicians to Medicare price regulations have rejected them in the recognition that participation in Medicare is voluntary.” [See also “Closed to New Medicaid Patients,” Ask FPM, November/December 2001, page 51.]

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Copyright © 2002 by the American Academy of Family Physicians.
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