How to Draft Written Agreements Between Supervising Physicians & Providers

When it comes to written agreements between supervising physicians, clarity is essential. These agreements are more than legal documents—they set the foundation for accountability, scope of practice, and workflow. Whether you’re a physician, NP, PA, or practice manager, understanding these agreements is vital for compliance and collaboration.

Key Takeaways

Written agreements between supervising physicians and midlevel providers outline scope of practice and ensure compliance.
State-specific laws dictate the requirements, making it critical to check local boards.
Include key details like charting deadlines, supervision requirements, and billing protocols.
Regularly renew agreements to avoid legal risks and maintain clarity.
Tailor agreements to your practice type—solo or group—for maximum efficiency.

What Are Written Agreements Between Supervising Physicians and Midlevel Providers?

These agreements are essentially the ground rules for collaboration between supervising physicians and midlevel providers (in this case, NPs and PAs).

Depending on your state, they may be legally required, reviewed by a board, or just strongly encouraged. The purpose? To outline responsibilities, define scope of practice, and ensure accountability on both sides.

First Things First: Check Your Local Boards

If you’re drafting a written agreement between supervising physicians and midlevel providers, your first step is to check your state’s medical and nursing boards.

Here’s why:

Requirements vary state to state. Some states require a written agreement for NPs, while others don’t.
The frequency of reviews and renewals also depends on local laws. You may need to update it annually, biennially, or whenever major changes occur.

Pro tip: Don’t just assume you know the rules—double-check! You can usually email or call your state’s board for clarification if their website leaves you scratching your head.

What Should Be Included in a Written Agreement?

This is where the fun starts (well, as fun as legal documents can get).

A written agreement between supervising physicians and midlevel providers is the perfect opportunity to include everything you need, legally and logistically.

Let’s break it into two categories:

1. State-Required Essentials

These will depend on your board’s guidelines but often include:

Supervision hours: How often the physician will be available to consult.
Scope of practice: What the midlevel provider is allowed to do (and not do) under state law.
Specific privileges: For example, prescribing medications or performing certain procedures.

2. Your Practice’s Expectations

Here’s where you can get specific about how you want things to run. Some key points to consider:

Charting deadlines: Include clear timelines for completing, signing, and locking notes after patient visits. This isn’t just about efficiency—it affects continuity of care, patient safety, and revenue.
Incident-to billing requirements: If you’re using incident-to billing, lay out the exact steps the midlevel provider needs to follow to qualify for it.
Practice style alignment: This is where you can include expectations about patient care philosophy and approach. For example, allowing providers to have their own style while staying aligned with your standards.

Why Charting Deadlines Are Critical

Let’s pause and talk about charting deadlines.

Including this in a written agreement between supervising physicians and midlevel providers is a game changer for any practice. Why?

Revenue flow: Claims can’t be submitted until notes are completed, signed, and locked. Delays in charting = delays in revenue.
Patient care: Charting impacts continuity of care and patient safety. A lag in documentation can lead to critical oversights.

If midlevel providers aren’t staying on top of this, it can derail your entire practice. So don’t skip this part—spell out expectations clearly!

What About Incident-to Billing?

If your practice is using incident-to billing, your written agreement is the perfect place to outline the steps and expectations.

For example:

The midlevel provider may need to ensure the supervising physician is physically present in the office during certain patient encounters.
Documentation must reflect the appropriate collaboration.

This protects your practice from billing mistakes and ensures compliance with Medicare guidelines.

Don’t Slack on Renewals

Here’s where a lot of practices get into trouble: renewals.

Some states don’t require you to submit a written agreement between supervising physicians and midlevel providers to the board. But they still expect you to review and renew it on a regular basis.

If you’re not keeping up with this, you’re exposing yourself to unnecessary liability. Imagine explaining to a board investigator why your written agreement hasn’t been updated in five years. Not fun, right?

Practical Tips for Staying Compliant

Set reminders. Use a digital calendar or task management app to alert you when it’s time for a review.
Communicate clearly. Make sure everyone on your team knows the rules and expectations.
Fix problems ASAP. If you realize something’s out of date, don’t panic—just fix it immediately.

Diving Deeper into Written Agreements Between Supervising Physicians and Midlevel Providers

Alright, let’s dig a little deeper into written agreements between supervising physicians and midlevel providers. In this section, we’ll cover legal considerations, handling disagreements, and even provide a sample outline to help you craft the perfect agreement for your practice.

Legal Considerations for Written Agreements Between Supervising Physicians

When it comes to healthcare, legal compliance is non-negotiable. A poorly written agreement—or worse, no agreement at all—can open up a can of worms for your practice. Think of malpractice lawsuits, lost revenue, or even licensing issues.

Here’s what you must consider:

1. Scope of Practice

Clearly define what the midlevel provider is allowed to do under state law. The agreement should outline:

Procedures they can perform
Prescriptive authority (if any)
Any limitations or restrictions

For example:
If your state doesn’t allow NPs to prescribe certain medications without direct supervision, make that crystal clear in the agreement.

2. Liability Coverage

Spell out who is responsible in the event of a legal claim. While the supervising physician typically carries ultimate liability, the agreement can protect both parties by detailing:

Insurance requirements for the midlevel provider
Scenarios where responsibility shifts

3. State-Specific Documentation Rules

Some states require specific language in written agreements between supervising physicians and midlevel providers. Missing these nuances could invalidate your agreement in the eyes of the law.

Example:
In Texas, agreements for PAs must include details about chart reviews and consultation requirements. In contrast, California might require different details for NPs.

4. Incident-to Billing Compliance

This is a legal minefield if not handled correctly. Make sure your agreement reflects Medicare or payer-specific requirements, including:

Physician presence requirements
Documentation protocols
Scenarios where incident-to billing is prohibited

Handling Disagreements Between Supervising Physicians and Midlevel Providers

It’s not all sunshine and roses in the world of supervising physicians and midlevel providers. Sometimes, disagreements arise—and without a well-thought-out agreement, these disputes can snowball into major issues.

What Can Go Wrong?

Midlevel providers may overstep their scope of practice.
Supervising physicians may fail to provide adequate oversight.
Confusion can arise over responsibilities, such as charting deadlines or billing protocols.

How a Written Agreement Helps:

A clear, detailed agreement can act as a neutral reference point during disputes. For example:

If the midlevel provider feels micromanaged, the agreement can clarify the expected level of supervision.
If the supervising physician is frustrated by delays in charting, the deadlines outlined in the agreement can guide resolution.

Sample Outline for a Written Agreement Between Supervising Physicians and Midlevel Providers

Now, let’s get practical. Below is a sample structure for your agreement. Feel free to tweak it based on your practice and state requirements.

Sample Written Agreement

Agreement Between Supervising Physician and Midlevel Provider

Effective Date: [Insert Date]
Review Date: [Insert Date]

Parties Involved:

Supervising Physician: [Insert Name]
Midlevel Provider: [Insert Name]

Scope of Practice:

[Define procedures and services the midlevel provider is authorized to perform.]
[List any limitations or restrictions based on state law.]

Supervision Requirements:

Frequency of Supervision: [E.g., weekly, monthly, as needed]
Chart Review Expectations: [E.g., 10% of charts reviewed weekly]
Consultation Availability: [E.g., Supervising physician must be available via phone during working hours.]

Charting Deadlines:

All patient charts must be completed, signed, and locked within [Insert Timeframe] of patient encounter.

Billing and Revenue Protocols:

Midlevel provider agrees to follow all guidelines for incident-to billing, including:
- [E.g., Ensuring the supervising physician is onsite for incident-to claims.]
- [E.g., Proper documentation reflecting collaboration.]

Performance Expectations:

Midlevel provider will adhere to the following:
- [Insert specific standards for patient care, communication, and timeliness.]
- [Insert expectations for attending training or continued education.]

Liability Coverage:

Supervising physician agrees to carry liability insurance of [Insert Amount].
Midlevel provider must maintain liability insurance of [Insert Amount].

Termination Clause:

Either party may terminate this agreement with [Insert Timeframe] written notice.

Signatures:

Supervising Physician: ___________________________
Midlevel Provider: ___________________________

Why You Can’t Skip the Renewal Process

Let’s revisit an important point: renewals.

Even if your state doesn’t require you to send the agreement to a board, failing to update it can:

Expose you to liability. If a patient files a complaint, an outdated agreement will look really bad during an investigation.
Create confusion. Midlevel providers may assume their scope has expanded or changed if there’s no consistent review.
Damage your practice’s reputation. Patients and staff expect you to run a tight ship. Don’t let administrative sloppiness get in the way.

Pro tip: Automate your reminders.

Use software like Google Calendar or project management tools (Trello, Asana, etc.) to ping you months before the renewal deadline.

Bringing It All Together

A written agreement between supervising physicians and midlevel providers isn’t just a legal checkbox—it’s your blueprint for collaboration, compliance, and success.

From charting deadlines to billing rules, every detail you include strengthens your practice and protects your team.

Tailoring Written Agreements for Solo vs. Group Practices

When it comes to written agreements between supervising physicians and midlevel providers, the structure and expectations may vary depending on whether you’re working in a solo practice or a group setting. Let’s break it down to make sure your agreement reflects the nuances of your specific work environment.

Written Agreements in Solo Practices

If you’re a supervising physician running a solo practice, the written agreement will often require more direct oversight and specificity because you’re the only person responsible for the midlevel provider.

Key Considerations for Solo Practices:

Supervision Availability:
Since you’re the sole supervisor, include clear instructions on how midlevel providers can reach you in real-time for consultation (e.g., phone, email, telemedicine platforms).
Backup Plan:
Life happens—what if you’re unavailable due to illness or vacation? Address how the midlevel provider should proceed in your absence. For example, include protocols for referring to an external covering physician or pausing certain procedures.
Streamlined Expectations:
Solo practices often have fewer layers of management, which means you can tailor the agreement to your specific working style. For example, outline preferences for charting, patient interaction, and workflow efficiency.

Written Agreements in Group Practices

In a group practice setting, there may be multiple supervising physicians overseeing multiple midlevel providers. This can make things more complex, but it also allows for more flexibility.

Key Considerations for Group Practices:

Shared Supervision:
Include guidelines on how multiple supervising physicians will collaborate to oversee the midlevel provider. For example, will you rotate responsibilities weekly? Or will certain physicians oversee specific patient populations?
Team Communication:
In a group practice, communication is key. Outline how information will flow between supervising physicians and midlevel providers. For instance:
- Weekly team meetings for case reviews.
- Using shared EMR messaging systems for quick consultations.
Unified Standards:
In a group practice, consistency matters. Ensure the agreement reflects standardized expectations for all midlevel providers in the practice—this avoids confusion and ensures everyone is on the same page.

Additional Details Based on State Requirements

Each state has its own unique laws governing the relationship between supervising physicians and midlevel providers. Here are a few examples to guide you:

California:

Nurse practitioners must have a Standardized Procedure Agreement (SPA) rather than a traditional written agreement. Make sure yours reflects California’s specific requirements.

Texas:

Physician assistants must operate under a written agreement that includes specific guidelines for chart reviews and consultative availability.

Florida:

Supervising physicians must register their agreements with the state board and include details on the specific practice setting.

New York:

Midlevel providers like NPs can practice independently after completing certain hours, but if under supervision, written agreements must still outline collaboration expectations.

Bottom line? Always check your state’s medical board and nursing board for updates, especially as regulations change frequently.

FAQ: Written Agreements Between Supervising Physicians and Midlevel Providers

If you’re diving into the nitty-gritty of written agreements between supervising physicians and midlevel providers, chances are you have a few questions. Below, we’ve compiled the most frequently asked questions to make sure you’re fully informed and ready to create a rock-solid agreement for your practice.

What is a written agreement between supervising physicians and midlevel providers?

A written agreement is a formal document that outlines the working relationship between supervising physicians and midlevel providers like nurse practitioners (NPs) and physician assistants (PAs). It details responsibilities, scope of practice, supervision requirements, and other expectations to ensure compliance with state laws and practice standards.

Are written agreements legally required?

It depends on your state laws.

Some states require written agreements to be submitted to the medical or nursing boards for approval.
Others mandate that the agreement is kept on file and reviewed periodically but don’t require submission.
A few states may not require written agreements at all for certain midlevel providers, like nurse practitioners practicing independently.

Tip: Check your state’s medical board and nursing board for specific requirements.

What should be included in a written agreement?

A written agreement between supervising physicians and midlevel providers should include:

Scope of practice (what the midlevel provider can and cannot do).
Supervision details (how often and in what capacity the physician will oversee the midlevel provider).
Charting deadlines (timeframes for completing, signing, and locking notes).
Billing protocols, especially for incident-to billing.
Expectations for patient care and workflow.
Renewal and review timelines.
Liability coverage requirements.

What happens if the agreement isn’t updated or renewed?

Failing to update or renew a written agreement can expose your practice to serious legal risks.

If a patient complaint or audit arises, an outdated agreement could make your practice look sloppy or non-compliant.
Your midlevel providers may unintentionally act outside their scope due to unclear or outdated instructions.
You may face penalties or investigations from your state’s medical board.

How often do written agreements need to be reviewed?

This varies by state, but common requirements include:

Annually
Biennially (every two years)
After any significant changes in scope of practice, responsibilities, or state regulations.

Even if your state doesn’t mandate a review, best practice is to revisit the agreement annually to keep it current.

What is incident-to billing, and how does it relate to written agreements?

Incident-to billing allows a practice to bill certain services performed by midlevel providers under the supervising physician’s name, usually at 100% of the physician’s Medicare rate.

To qualify for incident-to billing:

The supervising physician must be physically present in the office suite during the patient encounter.
The care must be part of a treatment plan initiated by the physician.
Documentation must reflect the supervising physician’s involvement.

Your written agreement should outline these requirements to ensure compliance with Medicare rules.

Can a written agreement protect the supervising physician’s license?

Yes! A written agreement between supervising physicians and midlevel providers acts as a legal document that:

Clarifies expectations: It ensures both parties know their responsibilities, reducing the likelihood of misunderstandings.
Provides evidence of oversight: If a midlevel provider steps outside their scope, the agreement shows the supervising physician communicated the proper rules.
Supports compliance: If audited, it demonstrates that your practice adheres to state laws and professional standards.

What happens if there’s a disagreement between the supervising physician and the midlevel provider?

Disputes can and do happen. Common issues include:

Midlevel providers feeling micromanaged.
Supervising physicians frustrated with delays in charting or billing.
Confusion about scope of practice.

A well-written agreement acts as a neutral reference point to resolve these disputes. For example:

If the midlevel provider is slow on charting, the deadlines outlined in the agreement provide accountability.
If a physician is unavailable for consultation, the agreement can clarify the protocol for such situations.

Can a supervising physician oversee more than one midlevel provider?

Yes, but the specifics depend on state regulations.

Some states limit the number of midlevel providers a physician can supervise at one time.
Others require specific agreements for each provider.

Check your local laws to make sure you’re within the legal limits.

Can a written agreement be customized?

Absolutely! In fact, it should be tailored to your practice’s unique needs. Some factors to consider when customizing:

The type of practice (e.g., solo vs. group).
The scope of services offered (e.g., primary care vs. specialty care).
Your workflow preferences (e.g., charting deadlines, billing protocols).

Customizing ensures that the agreement is not only legally compliant but also practical and effective for your day-to-day operations.

What happens if a midlevel provider violates the agreement?

If a midlevel provider violates the written agreement, the supervising physician is still ultimately responsible for oversight. However, the agreement can help in several ways:

Documented accountability: It proves the provider was made aware of their responsibilities and limitations.
Basis for corrective action: The agreement can guide disciplinary steps or retraining.
Legal protection: It may help the supervising physician demonstrate compliance with their obligations if the issue escalates to a board or legal matter.

What are the most common mistakes in written agreements?

Some common pitfalls include:

Failing to include state-specific requirements.
Using vague language that leads to interpretation disputes.
Not specifying charting deadlines, which can delay revenue and impact patient care.
Overlooking renewal requirements.
Neglecting to include incident-to billing rules if applicable.

Can I use a template for a written agreement?

Templates are a great starting point, but don’t rely on them exclusively. Always:

Customize the template to reflect your practice’s needs.
Ensure it complies with your state’s specific laws and board requirements.
Have the final agreement reviewed by an attorney familiar with healthcare regulations.

How do I start creating a written agreement?

Here’s a simple plan to get started:

Research your state’s laws for supervising physicians and midlevel providers.
Draft the agreement using a template or outline, including all required elements (scope, supervision, billing, etc.).
Review the draft with all parties involved—supervising physician(s) and midlevel provider(s).
Consult a healthcare attorney to ensure compliance and completeness.
Finalize the agreement, sign it, and file it where required by law or internally for future reference.

Wrapping It All Up

Creating a written agreement between supervising physicians and midlevel providers is more than just a bureaucratic task—it’s a chance to align expectations, improve workflow, and ensure compliance. Whether you’re running a solo practice, managing a group setting, or navigating complex state laws, a solid agreement is your secret weapon for success.

By including essentials like scope of practice, charting deadlines, billing protocols, and supervision guidelines, you’re not only protecting your practice but also fostering a culture of accountability and collaboration.

Here’s your quick checklist:

Check state-specific requirements.
Define supervision expectations clearly.
Include practical details like charting deadlines and billing compliance.
Set up reminders for agreement renewals.
Tailor the agreement to your practice structure—solo or group.

By tackling all these details upfront, you’ll avoid future headaches, improve efficiency, and set the tone for a thriving practice.