The Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) do not preempt or override state scope of practice laws. Moreover, state laws regarding provider delegation to medical assistants are not altered or nullified when medical offices and clinics are owned, operated, or on the premises of a hospital that is required to meet CMS CoPs.
If you have been told that different health care professionals share identical authority to delegate to medical assistants, consider the following situation:
A practice management consultant is telling us that medical assistants working under the authority of a nurse practitioner (NP) have the identical scope of practice as medical assistants working under a physician assistant (PA). Is that legally accurate? The consultant is saying that this is the case because the educational and licensing requirements for NPs and PAs are the same.
The medical assisting scope of practice under nurse practitioner authority is not necessarily the same as the scope of practice under physician assistant authority. Nurse practitioners are governed by the state nurse practice act and the regulations of the state board of nursing, whereas physician assistants are governed by the physician assistant practice act (which is sometimes part of the medical practice act) and the regulations of the state board of medical examiners. Consequently, the NP legal delegation authority in a state often differs significantly from the PA legal delegation authority in the same state.
And although the educational and testing requirements for NPs and PAs are similar, they are not identical. I have read articles asserting that the “nursing model” under which NPs are trained is very different from the “medical model” under which PAs are trained. This is a debatable point. However, it is indisputable that the tasks delegable to unlicensed allied health professionals such as medical assistants by NPs and PAs practicing in the same state are sometimes very different.
Like most other health professions, medical assisting is governed primarily by state law. This is due to the wording of the Tenth Amendment to the United States Constitution:
The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.
Because the power to regulate professions and occupations is not delegated to the United States Congress in Article I of the Constitution, it remains within the sovereign authority of each state. This authority includes establishing education and credentialing prerequisites for the practice of a profession, delineating legal and ethical responsibilities for the professionals, and issuing and enforcing disciplinary standards for breaches of these responsibilities.
Therefore, the legal scope of practice of medical assistants (which is coterminous with the legal authority of licensed health care providers to delegate to medical assistants) is established by state legislation, regulations and policies of state boards that regulate health professionals who delegate to medical assistants, and common law principles arising from court decisions and usual and customary practice. Federal law, however, sometimes impacts medical assisting scope of practice. The meaningful use regulations of the Centers for Medicare & Medicaid Services (CMS) are a current and significant example. Federal statute and CMS rule require a certain percentage of medication/prescription, laboratory, and diagnostic imaging orders to be entered into the computerized provider order entry (CPOE) system by licensed health care professionals or “credentialed medical assistants” in order for a licensed eligible professional to receive incentive payments under the Medicaid Electronic Health Record (EHR) Incentive Program.
Determining whether you are successfully working within your legal scope of practice as a medical assistant requires recognizing some situational nuances, especially on the matter of delegation. The following demonstrates one such instance:
I work in an outpatient practice setting. At times, I work under the authority and supervision of a physician. At other times, I work under the authority of a nurse practitioner or a physician assistant. I have been informed that my legal scope of practice is the same regardless of which licensed provider is assigning tasks to me. Is this correct?
Not necessarily. Under the laws of most states, the medical assistants’ scope of practice is determined by the practice act and regulations of the delegating provider.
For example, the nurse practice act and the regulations and policies of the state’s board of nursing determine which tasks nurses (including advanced practice registered nurses [APRNs], such as nurse practitioners) are permitted to delegate to medical assistants.
On the other hand, the medical practice act and the regulations and policies of the state’s board of medical examiners delineate which duties physicians are allowed to assign to medical assistants. And physician assistant delegation authority is established by other state statutes, regulations, and policies.
There are legal nuances that must be taken into consideration. Some states permit nurse practitioners to work autonomously and without a collaborative practice agreement with a physician. In these states the delegation authority of autonomous nurse practitioners is determined by the nurse practice act and the rules of the board of nursing.
However, nurse practitioners in an independent-practice state may choose to work under physician authority and supervision, and physicians may assign nurse practitioners to oversee medical assistants who are performing tasks delegated to them by a physician. In such a case, both the medical practice act and the nurse practice act may have a bearing on the scope of practice of a medical assistant.
A resolution supporting medical assistants and CMAs (AAMA) was adopted by the House of Delegates of the Indiana State Medical Association (ISMA) in September 2018. The resolution was introduced by William W. Pond, MD. Tammy Daily, CMA (AAMA), liaison to the ISMA from the Indiana Society of Medical Assistants, and I helped craft the final language of the resolution. To read the adopted resolution, access the January/February 2019 Public Affairs article, “ISMA urges Indiana physicians to hire competent medical assistants,” on the AAMA website.