When advanced practice providers (APPs) have admitting privileges, they’re allowed to admit patients without the attending physician’s countersignature, assuming state law doesn’t stand in the way. But if APPs don't have admitting privileges, physicians will continue to be burdened by the countersignature requirement on admission orders.

So goes the push and pull of APPs—including nurse practitioners (NPs) and physician assistants (PAs)—even as they gain ground with state scope of practice laws, regulators, payers and some hospitals, said Meghan Cosgrove, senior associate general counsel at Beth Israel Lahey Health in Massachusetts. In the process, oversight has become more challenging. “It’s gotten more complicated,” she said Sept. 9 at a Health Care Compliance Association virtual conference.^[1] This is playing out against a backdrop of a physician shortage and attendant demand for APPs. Their use also brings a unique set of compliance risks, including hospital-employed APPs providing free services to private-practice physicians and mistakes around documentation requirements.

Although APPs are often granted hospital privileges without being members of the medical staff, “we’re on the precipice of a sea change,” Cosgrove said. “That aligns with CMS commentary. It expects all practitioners who are granted privileges to be appointed as members of the medical staff. There still may be pushback from the medical staff because it fears loss of control if they add APPs as members—sometimes there’s a cultural/political barrier—but in the marketplace, APPs often expect to be full members of the medical staff, Cosgrove said.