Is an NP a Licensed Independent Practitioner?

Carolyn Buppert, NP, JD

Disclosures

January 17, 2013

In This Article
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Question

Are NPs considered licensed independent practitioners? How is this determined?

Response from Carolyn Buppert, NP, JD
Attorney, Law Office of Carolyn Buppert P.C., Bethesda, Maryland

Defining a Licensed Independent Practitioner

Whether a nurse practitioner (NP) is considered a licensed independent practitioner depends on the wording of state law and which definition of "licensed independent practitioner" is being used.

The term "licensed independent practitioner" originated with The Joint Commission and is used in standards for privileging and credentialing. The Joint Commission also uses the term when discussing who can complete the admission history and physical for hospitalized patients. The Centers for Medicare & Medicaid Services (CMS) has since adopted the term, but for the most part, CMS uses the term only in regulations specifying who can order restraints, perhaps because The Joint Commission used it when discussing restraints. The US Health Resources and Services Administration (HRSA) also uses the term when talking about credentialing providers for health clinics.

According to The Joint Commission, a licensed independent practitioner is "any individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual's license and consistent with individually granted clinical privileges. When standards reference the term 'licensed independent practitioner,' this language is not to be construed to limit the authority of a licensed independent practitioner to delegate tasks to other qualified health care personnel (for example, physician assistants [PAs] and advanced practice registered nurses [APRNs]) to the extent authorized by state law or a state's regulatory mechanism or federal guidelines and organizational policy."[1]

HRSA defines the licensed independent practitioner as "a physician, dentist, NP, nurse midwife, or any other individual permitted by law and the organization to provide care and services without direction or supervision, within the scope of the individual's license and consistent with individually granted clinical privileges."[2]

Under The Joint Commission's definition, in states where they are not required to be supervised or directed by physicians, NPs are licensed independent practitioners, but they are not in states where such supervision or direction is required by law. To HRSA, however, all NPs are licensed independent practitioners. The HRSA definition identifies as licensed independent practitioners NPs "or others permitted by law and the organization to provide services without direction or supervision."

In a set of standards, The Joint Commission says that it does not determine whether a practitioner is a licensed independent practitioner but defers to state law for that determination.[1]

In a guest blog on the Commission's Website, Virginia McCollum, Associate Director of The Joint Commission Standards Interpretation Group, said, "Each state has different laws defining who can practice without supervision. For example, NPs are licensed in 14 states as independent practitioners (licensed independent practitioners); for the remaining states, they are licensed as practicing 'under supervision of a licensed independent practitioner.' Bottom line: Check your state for which professions...are licensed to practice independently."[3]

Let's look at 3 states' laws to determine whether NPs are licensed independent practitioners.

New Hampshire. Under New Hampshire law: "The APRN scope of practice, with or without compensation or personal profit, shall be limited to: (a) Performing acts of advanced assessment, diagnosing, prescribing, selecting, administering, and providing therapeutic measures and treatment regimens; (b) Obtaining consultation, planning, and implementing collaborative management, referral, or transferring the care of the client as appropriate; and (c) Providing such functions common to an NP for which the APRN is educationally and experientially prepared and which are consistent with standards established by a national credentialing or certification body recognized by the National Council of State Boards of Nursing and approved by the board in the appropriate APRN role and specialty."[4]

The portion of New Hampshire law cited above gives APRNs the authority to perform medical evaluation/management -- that is, diagnose and prescribe treatments. There are no requirements for physician collaboration, direction, or supervision. So, in New Hampshire, APRNs are licensed independent practitioners.

Oklahoma. Under Oklahoma law, an NP "functions within the certified NP scope of practice for the selected area of specialization."[5] To determine whether a specific function is within the NP's scope of practice in Oklahoma, 7 questions must be answered, starting with, "If you are an advanced practice nurse, is the act for advanced practice nurses within the generally recognized scope and standards of your certifying body?"[6] Oklahoma law also calls for direction and supervision: "An advanced registered NP in accordance with the scope of practice of the advanced registered NP shall be eligible to obtain recognition as authorized by the Board to prescribe, as defined by rules and subject to the medical direction of a supervising physician."[5] So, in Oklahoma, NPs are not licensed independent practitioners under The Joint Commission definition but are licensed independent practitioners under the HRSA definition.

Michigan. In Michigan, there is no statutory or regulatory scope of practice for an NP. According to statute and regulation, NPs have the scope of practice of a registered nurse. Physicians can, by Michigan state law, delegate their authority to perform medical acts.[7] So, because NPs in Michigan cannot perform medical acts without delegation, they cannot be considered licensed independent practitioners under The Joint Commission definition, but they would be licensed independent practitioners under the HRSA definition.

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