Meeting the Standard of Care

Whether you are a referral coordinator or a medical assisting professional, knowing when the standard of care has been met within the process of a referral from a primary care physician to a specialist is valuable. I recently received the following question on that matter:

When referrals are processed in an [outpatient] setting from a patient’s [primary care physician] to a specialist, at what point is the legal standard of care met? Is it when [the primary care physician] gets a written response from [the specialist] ([e.g., “the patient] is scheduled on this date at this time”)? Or [is the standard of care met] when the [primary care physician] receives an actual chart note from the referred specialist?

… Also, are the rules the same for follow-up [on] diagnostic orders?

My legal opinion is that the standard of care for the primary care physician has not been met until (1) the primary care physician receives official notice that the patient has been seen by the specialist or (2) the specialist has declined the referral. As I see it, the primary care physician has a legal duty to take appropriate action vis-à-vis the patient if the specialist does not agree to see the patient.

Moreover, until actual results are obtained, the order is still considered to be in process.

The same legal principles would apply to diagnostic orders.

The AAMA Protects the Medical Assisting Right to Practice

The American Association of Medical Assistants® (AAMA) engages in state and federal advocacy to protect patients from substandard medical assisting services. This objective is achieved by drafting legislation and regulations that ensure that potentially patient-jeopardizing tasks are delegable to only knowledgeable and competent medical assistants who meet the following three standards:

• Have completed education of appropriate and adequate depth, breadth, and rigor
• Have been awarded an accredited credential—such as the CMA (AAMA)®—that measures required medical assisting knowledge and its application
• Have demonstrated continuing competence by periodic recertification

As a result of accomplishing this objective, knowledgeable and competent medical assistants are differentiated in law from other medical assistants.

As part of the AAMA mission, AAMA staff monitor and pursue advocacy opportunities on the federal and state levels that are most strategically advantageous. The following are some examples of AAMA advocacy that have increased patient protection by requiring medical assistants to have appropriate as well as adequate education and/or credentialing.

Arizona

In 2017, AAMA staff urged the Arizona Medical Board (AMB) to more precisely define approved medical assistant program in its delegation rules. The AMB saw the wisdom of the AAMA position and changed the wording of its regulations.

North Dakota

Because of a 2004 ruling by the North Dakota attorney general, medical assistants were no longer permitted to be delegated and perform medication administration. Partly through the efforts of AAMA staff, medication assistant regulations were amended to permit medical assistants who had completed an accredited program and held an accredited medical assisting credential to be delegated certain types of medication administration.

CMS meaningful use requirements of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs

The initial set of proposed rules published by the Centers for Medicare & Medicaid Services (CMS) in 2010 to implement the computerized provider order entry (CPOE) requirements of the Medicare and Medicaid EHR Incentive Programs allowed only “licensed health care professionals” to enter orders into the CPOE system for meaningful use calculation purposes. Staff of the AAMA petitioned CMS to recognize “credentialed medical assistants,” as well as licensed professionals, for meaningful use order entry. In 2012, CMS was persuaded and changed the wording of its final rule to include “credentialed medical assistants.” This was the first time that credentialed medical assistants were distinguished from noncredentialed medical assistants in federal law.

For more information on these achievements, read the Public Affairs articles “Comments to the Arizona Medical Board” (November/December 2017), “North Dakota CMAs regain injections” (September/October 2005), and “AAMA triumphs in CMS order entry rule” (November/December 2012) in past CMA Today issues.

Who Can Take the CMA (AAMA)® Exam?

Q. Who is eligible to take the CMA (AAMA)® Certification Exam?

A. The only individuals eligible to take the CMA (AAMA) Certification Exam and become CMAs (AAMA) are graduates or graduating students of medical assisting programs that fall within one of the following categories:

• Accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP)
• Accredited by the Accrediting Bureau of Health Education Schools (ABHES)
• Meets the criteria for the time-limited Certification Exam Eligibility Pilot Program

The Certification Exam Eligibility Pilot Program is a three-year pilot program, begun August 2019, that allows graduates of postsecondary (college-level) medical assisting programs to take the CMA (AAMA) Exam if the program meets certain requirements, including the program being part of an institution accredited by an accrediting body recognized by either the United States Department of Education (USDE) or the Council for Higher Education Accreditation (CHEA).

Hopeful exam candidates can gather all required documentation and submit their documentation for review—to see if they are eligible under the pilot program—for free online via the AAMA website.

NP Delegation in South Carolina: State Law Permits Nurse Practitioner Delegation to Medical Assistants

Conflicting information has been circulating about whether South Carolina nursing law permits licensed nurses—including advanced practice registered nurses (APRNs), such as nurse practitioners (NPs)—to delegate tasks to medical assistants.

Nevertheless, South Carolina law specifically authorizes licensed nurses, including NPs, to delegate certain nursing tasks to knowledgeable and competent unlicensed assistive personnel (UAP), such as medical assistants, who are working under appropriate nurse supervision.

Administration of medication, however, is a task licensed nurses cannot legally delegate to UAP (such as medical assistants) under South Carolina nursing law.

Review the supporting evidence in the January/February 2020 Public Affairs article, “NP Delegation in South Carolina,” on the AAMA website.

New Alaska Standards for Delegation of Certain Duties

The Alaska State Medical Board has added a new section to its regulations that establishes standards and conditions under which a licensed physician (doctor of medicine or osteopathic medicine), podiatrist, or physician assistant may delegate certain medical duties to unlicensed professionals such as medical assistants.

These regulations remove any ambiguity from the assertion that knowledgeable and competent unlicensed allied health professionals such as medical assistants can legally perform intramuscular (IM), subcutaneous (subq), and intradermal (ID) injections delegated by a licensed provider under the provider’s direct/on-site supervision.

The regulations of the Alaska State Medical Board were finalized November 25, 2019, and went into effect December 25, 2019.

You can read the regulations by either accessing the December 2019 medical statues and regulations document (Page 37) via the Alaska State Medical Board webpage or the Alaska section of the AAMA State Scope of Practice Laws webpage on the AAMA website.

This is a significant scope of practice victory in Alaska, and I congratulate the Alaska Medical Assistant Society for its excellent and diligent work on strengthening and clarifying medical assistants’ right to practice!