There are more than 355,000 nurse practitioners (NPs)(1) and 168,000 physician assistants (PAs)(2) licensed in the United States, and these numbers are rising rapidly.
Major legislative efforts have aimed to broaden the scope of practice for advanced practice providers (APPs) and lessen requirements for physician oversight. Contrary to popular belief, this has not resulted in a decrease in APP collaboration with physicians.(3) Advanced practice provider supervision benefits APPs, their patients, and also the supervising physician by helping to ensure high-quality patient care and improved outcomes. It allows physicians to extend their capabilities and expand their reach. It offers flexibility, enabling physicians to continue practicing medicine while taking a step back from direct patient care.
Advanced Practice Provider Training and Scope of Practice
Advanced practice providers were introduced to expand access to care, respond to a growing physician shortage, promote team-based care, and contain healthcare costs.
Nurse practitioners form the largest subset of advanced practice registered nurses (APRNs). They undergo a two- to three-year master’s program with 500 to 1000 clinical hours. Training emphasizes health promotion and education. Other APRN types are nurse anesthetists, nurse midwives, and clinical nurse specialists.
Becoming a certified PA (PA-C) also requires a two- to three-year master’s program and includes between 2000 and 2500 clinical hours. PA education is based on a medical model, with a stronger foundation in basic sciences.
Advanced practice providers can practice across a variety of settings and specialties. They are more commonly found in rural and underserved regions than are physicians.(4) A high percentage of NPs are certified in primary care; more PAs work in surgical subspecialties and emergency medicine.
Advanced practice providers can diagnose, treat, and prescribe, although their precise scope of practice varies by state, including which procedures they can perform and which treatments require special training. Regulatory oversight comes mainly from state medical boards for PAs and nursing boards for NPs. Payer and employer policies can further restrict scope of practice.
Practice Authority and Supervision Requirements
Individual states have laws governing the level of physician supervision for APPs. Supervision refers to physician oversight of activities and decisions, balancing autonomy with access to medical expertise. Many healthcare professionals advocate for the use of the term collaboration instead of supervision to emphasize the teamwork between APPs and physicians.
As of 2023, 28 states permit NPs to practice independently(5); the remaining states mandate some form of physician supervision. Few states allow PAs to practice unsupervised, but efforts are underway to change this. Some states have more stringent supervision requirements than others, requiring varying degrees of physician onsite presence, chart cosigning, and face-to-face meetings. All states allow for indirect supervision in many situations, in which the physician is available for remote consultation.
Liability and Risk in Advanced Practice Provider Supervision
Supervising physicians have legal responsibility for the APP’s practice. Deficient supervision, poor communication, or delayed interventions can increase liability risks, including potential malpractice claims. If there are allegations of improper supervision or negligence, the state’s medical board can investigate the physician, potentially leading to fines, practice restrictions, or license revocation.
Some physicians avoid APP supervision out of concern regarding these risks; however, APP supervision is a valuable and necessary component of our healthcare system. Do not dismiss supervision positions solely because of the inherent risks involved. Instead, take time to mitigate risks by forming a supportive relationship with the APPs you supervise. Establish clear communication lines, document supervision activities, maintain professional liability insurance, and stay current on applicable laws, regulations, and standards of care.
Unconventional Advanced Practice Provider Supervision Jobs
Supervision of APPs, in a broad sense, is not unconventional; it has a common and well-established role within the healthcare industry. In fact, a majority of physicians routinely work with APPs.(6) Nonetheless, there are many less traditional APP supervision jobs. Many of these check the boxes for doctors seeking flexibility, remote work, and a less busy schedule.
Supervising Physician for Healthcare Corporations
Some healthcare organizations rely heavily on APPs to provide patient care services. Common examples include occupational health clinics, urgent care centers, and healthcare chains operating under a single management structure. Telemedicine companies are increasingly utilizing APPs as the main point of contact for straightforward patient visits.
In APP-centric care models, APPs deliver the core services of the business, but they still need physician supervision if required by the state. In many cases, the physician’s primary role is supervisory, with minimal direct patient care.
Supervising Physician for Advanced Practice Provider–owned Practices
Another option is supervising an NP or PA in a practice they own and operate. In an APP-owned practice, the absence of a corporation or third-party entity allows the physician and APP to tailor their collaboration to their work preferences and the practice’s needs.
Some states have rules regarding the conditions under which an APP can own a practice, such as having a certain amount of experience.
Supervising Physician for Healthcare Payer Home Visit Programs
Many commercial insurance companies, including Anthem, Humana, and Optum, operate home health evaluation programs in which NPs conduct in-person medical assessments to gather health information and coordinate care for insurance plan members. In states requiring supervision, physicians review member assessments, offer phone consultation when needed, and conduct other oversight work as required by the state. They do not personally conduct visits or evaluate patients.
In states restricting independent NP practice, these programs offer contracted roles for physicians that require as little as an hour or two of work per month. NPs focus on patient assessment and care coordination, rather than prescribing medications or providing treatment, which minimizes time and risk for the supervising physician.
Advanced Practice Provider Supervision as an Adjunct Role
Physicians in hospital and healthcare system leadership roles often supervise APPs. The supervision portion of the job is a distinct component of the overall position, so compensation can be separate from salary in the form of a stipend.
Becoming a Supervising Physician
Advanced practice provider supervising positions for licensed physicians of all specialties are available. It is not always necessary to have the same specialty as the APP, but you must have sufficient knowledge and experience related to the services the APP provides and conditions they treat.
There are multiple ways to find supervising jobs. National or multi-state healthcare corporations, telemedicine platforms, and insurance companies commonly post on job boards. Networking can identify opportunities with healthcare practices in your community. Advanced practice providers in solo practice often rely on existing relationships and word of mouth. You can contact intermediary matching services, such as Collaborating Docs and Supervising MD, which act as facilitators to connect APPs with supervising physicians.
After securing a position, you need to establish a supervision agreement with the APP and submit state-specific documentation. Companies may provide standard agreements, although you still need to review these to ensure they are in line with your practice preferences and state rules.
Do not confuse your supervision agreement with your employment agreement; they are separate but must align with one another. The supervising agreement describes the supervisory relationship, including the APP’s scope of practice, how the physician and APP will communicate, and a quality assurance plan. The employment or contractor agreement governs your relationship with the practice or company hiring you.
Compensation and Financial Considerations
Compensation for APP supervision roles varies; each model has its merits and limitations. The most common and straightforward arrangement is a flat fee, which provides a set amount regardless of the actual hours spent supervising. An hourly rate or a fee per chart review or per consultation will compensate you for your time but may not account for the responsibility and risk you assume. In some arrangements, compensation is tied to the practice’s profit or the APP’s billing, calculated as a percentage. Although potentially lucrative, this can introduce conflicts of interest and could create an incentive for overutilization of unnecessary services.
Limited data are available on how much physicians are being paid to supervise APPs. A large national survey of primary care NPs in 2017 reported a median fee of $500 per month, with a range up to $4,167 per month.(7) Monthly fees as high as $5,000 were reported in a study of psychiatrists.(8)
Physicians employed full-time by hospitals or healthcare systems who are asked to supervise an APP in addition to their regular duties may receive a stipend ranging from a few thousand dollars to tens of thousands of dollars per year.
Advanced Practice Provider Billing and Reimbursement
Advanced practice providers employed by a healthcare system or corporation usually are not involved in the compensation for their supervising physician; however, APP practice owners should bear in mind their practice’s bottom line when negotiating a supervising physician fee. In this context, it can be helpful to understand how medical billing and reimbursement work for APPs. Medicare, for instance, reimburses APPs at 85% of the physician rate for comparable services.
Billing structures differ between NPs and PAs. Whereas NPs can bill Medicare directly, PAs must route their billing through their supervising physician. Private insurers have varying policies — some may reimburse APPs at the same rate as physicians, whereas others offer a lower rate.
Billing practices also vary based on the APP’s licensure and work setting. Independent billing is common, with APPs using their own National Provider Identifier (NPI) numbers. Split or shared billing occurs when both the supervising physician and the APP are involved in patient care, billing separately for distinct services rendered. Incident-to billing is less common and involves billing for the APP’s services under the supervising physician’s NPI, typically in scenarios where direct supervision is involved.
References
NP Fact Sheet. American Association of Nurse Practitioners. 2022. www.aanp.org/about/all-about-nps/np-fact-sheet
American Academy of Physician Associates. About AAPA Fact Sheet. 2023. www.aapa.org/download/77924/
Najmabadi S, Honda TJ, Hooker RS. Collaborative practice trends in U.S. physician office visits: an analysis of the National Ambulatory Medical Care Survey, 2007–2016. BMJ Open. 2020;10(6):e035414. https://doi.org/10.1136/bmjopen-2019-035414
Everett CM, Schumacher JR, Wright A, Smith MA. Physician assistants and nurse practitioners as a usual source of care. J Rural Health. 2009;25:407-414. https://doi.org/10.1111/j.1748-0361.2009.00252.x
State Practice Environment. American Association of Nurse Practitioners. October 2022. www.aanp.org/advocacy/state/state-practice-environment
Peterson LE, Phillips RL, Puffer JC, Bazemore A, Petterson S. Most family physicians work routinely with Nurse Practitioners, Physician Assistants, or Certified Nurse Midwives. J Am Board Fam Med JABFM. 2013;26:244-245. https://doi.org/10.3122/jabfm.2013.03.120312
Martin B, Alexander M. The economic burden and practice restrictions associated with collaborative practice agreements: a national survey of Advanced Practice Registered Nurses. J Nurs Regul. 2019;9(4):22-30. https://doi.org/10.1016/S2155-8256(19)30012-2
Phoenix BJ, Chapman SA. Effect of state regulatory environments on advanced psychiatric nursing practice. Arch Psychiatr Nurs. 2020;34:370-376. https://doi.org/10.1016/j.apnu.2020.07.001