Collaboration Regulations for Nurse Practitioners & Physician Assistants: The Full Breakdown

When Nurse Practitioners (NPs) and Physician Assistants (PAs) seek to collaborate with physicians, the most common focus is whether they can practice independently or need a formal collaboration agreement. But that’s only scratching the surface.

Collaboration isn’t just about whether a state requires a supervising or collaborating physician. It’s also about Corporate Practice of Medicine (CPOM) laws, delegation rules, prescriptive authority, scope of practice, and telemedicine regulations—all of which can impact compliance and business viability.

If you’re an NP or PA looking to establish your practice, or a physician considering collaboration, understanding the full regulatory landscape is critical. Here’s what you must evaluate before structuring a collaboration agreement.

1. Corporate Practice of Medicine (CPOM) Regulations: Who Can Own the Practice?

One of the biggest blind spots for NPs and PAs when structuring collaborations is Corporate Practice of Medicine (CPOM) laws. These state-level regulations restrict who can own, manage, or profit from a medical practice.

Key Considerations:

• Can an NP or PA own a practice in your state? Some states (e.g., Arizona, Oregon) allow full practice authority, while others (e.g., Texas, California) require a physician to own at least a portion of the practice.
  
• Do you need a Management Services Organization (MSO)? In states with CPOM laws, NPs and PAs often use MSOs to handle non-clinical operations while physicians legally own the practice.
  
• Are there limitations on fee-splitting? Some states prohibit physicians from receiving a percentage of revenue from NPs/PAs, requiring flat-fee arrangements instead.
  
  

States With Strict CPOM Laws:

• California
• New York
• Texas
• Illinois
• New Jersey

If you’re in one of these states, consult legal counsel before structuring ownership agreements—violating CPOM can trigger severe penalties.

2. Collaboration & Delegation Agreements: Defining the Relationship

Many states require a formal collaboration or delegation agreement between NPs/PAs and physicians. These documents outline responsibilities, supervision levels, and practice limitations.

What to Look For in a Collaboration Agreement:

1. Defined Scope of Supervision – Does the state require direct supervision, or can it be indirect? Some states mandate chart reviews, site visits, or set a limit on how many NPs/PAs a physician can oversee.
   
   
2. Emergency & Escalation Protocols – Some states require a plan for handling medical emergencies or complex cases.
   
   
3. Documentation & Auditing – Many states require periodic compliance audits and proof that supervision is occurring.
   
   
4. Geographic Restrictions – Some states limit supervision to a certain mileage radius.
   
   

Example State Variations:

• Texas – Physicians must review 10% of charts per month and have face-to-face meetings with NPs/PAs every quarter.
  
• Florida – A PA can be supervised by a physician remotely, but the physician must be "reasonably available" for consultation.
  
• Alabama – The state board must approve collaboration agreements before NPs/PAs can practice.
  
  

Failing to document and maintain these agreements properly can result in license suspension or fines.

3. Prescriptive Authority: What Can NPs & PAs Legally Prescribe?

Many NPs and PAs assume their collaboration agreement automatically allows them to prescribe medications. Not true. Prescriptive authority is regulated separately from general practice agreements.

Key Considerations:

• Do you need a separate prescriptive authority agreement? Some states require an additional agreement with specific details on controlled substances.
  
• Can you prescribe controlled substances? Many states limit or restrict Schedule II drugs like opioids.
  
• Are there mandatory physician reviews? Some states require periodic chart audits for all prescriptions.
  
  

State-Specific Prescriptive Authority Rules:

• Georgia – NPs can prescribe Schedule III-V drugs, but Schedule II requires physician oversight.
  
• Kentucky – NPs need a "Collaborative Agreement for Prescriptive Authority" (CAPA-CS) for controlled substances.
  
• California – PAs must have a signed delegation of services agreement specifying what medications they can prescribe.
  
  

Failing to comply with prescriptive authority laws can result in DEA violations and loss of prescribing privileges.

4. Scope of Practice Regulations: What Are the Legal Boundaries?

Scope of practice laws dictate what services NPs and PAs can legally provide. Many states have specific limitations on:

• Procedural privileges (e.g., sutures, joint injections, dermatologic procedures)
  
• Diagnostic capabilities (e.g., ordering MRIs, X-rays, lab work)
  
• Independent vs. collaborative decision-making authority
• Types of services allowed (e.g. aesthetics vs. mental health vs. long-term care)
  
  

Real-World Example:

In Florida, while it allows for NPs to practice under a collaboration agreement, laser procedures must be authorized after a physician consultation. Additionally, a physician must be within 45-miles of the practitioner, making it harder for aesthetic and med spas to operate compliantly without a physically present or involved physician. 

5. Telemedicine Regulations: State-Specific Compliance Matters

Telemedicine is one of the most overlooked aspects of collaboration agreements. Many states have specific requirements around supervision, licensing, and prescribing for virtual care.

Key Considerations for Telehealth Compliance:

• Are there in-person visit requirements? Certain states mandate an initial in-person visit before telehealth prescribing is allowed.
  
• Can controlled substances be prescribed via telemedicine? The Ryan Haight Act and state-specific laws regulate remote prescribing of controlled medications.
  
  

Example Telehealth Regulations:

• Texas – Physicians must review telehealth encounters periodically.
  
• New York – NPs can independently provide telehealth but must follow state-specific consent laws.
  
• Nevada – Telemedicine collaborations must be registered with the state board.
  
  

Final Thoughts: A Comprehensive Regulatory Review is Essential

Most NPs, PAs, and physicians focus only on collaboration agreements—but that’s just one piece of the puzzle.

When structuring a compliant collaboration, consider:
✅ CPOM laws – Who can own the practice?
✅ Collaboration agreements – What’s required?
✅ Prescriptive authority – What can you legally prescribe?
✅ Scope of practice – What services can you provide?
✅ Telemedicine regulations – Are there remote care limitations?

Skipping any of these areas can lead to regulatory violations, lost revenue, and even disciplinary action.

Need Help Structuring a Compliant Collaboration?

If you’re an NP, PA, or physician looking to set up a compliant collaboration, we provide strategic guidance and regulatory insights. Contact us today for expert consultation on structuring agreements, navigating CPOM, and ensuring compliance.

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