delegation, On the Job, Scope of Practice

Relaying Providers’ Orders by Telephone

Part of the AAMA’s mission is to protect medical assistants’ scope of practice. Sometimes that means gathering evidence to prove that what other health professionals think is a limitation of medical assistants’ scope of practice is unsubstantiated by state law. Consider the following from a medical assistant in Wisconsin:

I work in a small physician-owned clinic. Our primary care providers visit two local skilled nursing facilities each month. … [Does] our state permit nurses to take a provider’s order by telephone that is conveyed by a medical assistant? These telephone orders are always followed up by a written electronic order from the provider. [But] we are being told that nursing home staff will only take telephone orders directly from licensed health professionals.

Why would this be any different from a provider directing one of our medical assistants to convey a normal lab value? Our providers would spend all day calling the nursing homes if medical assistants cannot relay information at the request of the provider. If the nursing home staff members do not understand the order, they can always ask for clarification from one of our providers.

I reviewed the nurse practice act and the regulations and policies of Wisconsin’s state board of nursing. I found nothing stating that registered nurses (RNs) and licensed practical nurses (LPNs) are prohibited from receiving and executing orders from a licensed provider (e.g., physicians, nurse practitioners, physician assistants) that are transmitted verbatim by telephone by an unlicensed allied health professional, such as a medical assistant.

Unless state law specifically indicates otherwise, my legal opinion is that knowledgeable and competent medical assistants are permitted to convey verbatim information (including orders) on behalf of the delegating provider and receive verbatim information for the overseeing provider. Information conveyed by telephone should be followed up by a written order (electronic or hard copy).

On the Job, Professional Identity

Medical Assistants Must Not Refer to Themselves as “Nurses”

Medical assistants must scrupulously avoid conveying the message that they are nursing personnel or members of any profession other than medical assisting.

It is unethical, illegal, and a disservice to the medical assisting profession for medical assistants to refer to themselves as “nurses,” “office nurses,” “doctors’ nurses,” or any other generic term that even remotely implies that medical assistants are nurses.

Review the supporting evidence within excerpts from the National Council of State Boards of Nursing NCSBN Model Act (2012) and several states’ nurse practice acts in the May/June 2019 Public Affairs article, “Medical Assistants Must Not Refer to Themselves as ‘Nurses,’” on the AAMA website.

delegation, On the Job, Scope of Practice

Delegation Authority of Nurse Practitioners vs. Physician Assistants

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.

Scope of Practice

Is Medical Assisting Governed by State Law or Federal Law?

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.

Certification and the CMA (AAMA) Credential, medication assistant, On the Job, Professional Identity

Levels of Medical Assisting

Here is an interesting question about “levels” of medical assisting:

I work for a very large cardiology practice in North Carolina. Is it permissible to establish tiers of medical assistants based on their skill sets? For example, are we permitted under North Carolina law to have categories such as Medical Assistant I, Medical Assistant II, Medical Assistant III based on the medical assistant’s education, credentialing, and skill sets?

North Carolina law does not forbid employers from establishing tiers or levels of medical assistants. An employer is allowed to determine what elements of knowledge and skill are required for each category of medical assistants and what tasks should be assigned to medical assistants in the respective categories.

However, these levels should not have “CMA” in their titles. The American Association of Medical Assistants (AAMA) has intellectual property rights to the phrase “certified medical assistant” and the initialisms “CMA (AAMA)” and “CMA.”

Titling these classifications as Medical Assistant I, II, III is permitted under North Carolina law and does not infringe on the trademark and intellectual property rights of the AAMA. See the State Scope of Practice Laws webpage on the AAMA website to access key state legislative materials pertaining to medical assisting.