Stresses on Wisconsin’s medical systems have prompted re-evaluation of provider licensing requirements. Three recent pieces of legislation seek to remove barriers to practice and expand access to medical care. This article discusses recent changes and highlights considerations for health insurers, physician clinics, and hospitals in response to these new credentialing standards.
Wisconsin Act 23 Regarding Physicians Assistants
The passage of Wisconsin Act 23 updated and expanded the licensure of physicians assistants (PAs) practicing in Wisconsin.
Prior to the Act’s publication on March 27, 2021, physician assistants were required to maintain a relationship with a physician who served in the capacity of a supervisor, overseeing the PA’s patient care. WI Act 23 elevates PAs and requires collaboration with a physician in lieu of supervision. The collaborative relationship must be evinced in part by a written collaboration agreement addressing availability and timeliness of communications between the PA and the physician.1 Consistent with this change, PAs are now individually and independently responsible for the quality of care rendered.
The law created the Physician Assistant Affiliated Credentialing Board (PA board), which will go into effect April 1, 2022. Wis. Stat. chapter 448, subchapter VIII established the new PA board, which replaces the current Council on Physician Assistants.
The PA board is empowered to establish grounds for professional discipline and to impose that discipline when required. It is also charged with establishing rules for the updated licensure – a task the board will take on later this year. Announcements from the PA board and new rules will become available through the Department of Safety and Professional Services.
In addition, Act 23 creates new practice rights for PAs. Among them:
PAs may now order, prescribe, procure, dispense, and administer prescription drugs, with a valid DEA registration.
Previously PAs could not delegate medical care tasks to other providers. Now they are free to do so, within limits. The delegated provider must be clinically trained and competent to perform the delegated task.
Whereas PAs previously were required to work with a physician at a ratio of one physician per four PAs, that restriction has been removed, and a physician may collaborate with numerous PAs concurrently.
Act 23 also creates new responsibilities for PAs. Because PAs are now independently responsible for the care rendered, they are required to maintain malpractice liability insurance coverage in accordance with Wis. Stat. section 655.23 (4).
Additionally, a PA must complete new continuing education requirements and now has a mandatory reporting duty when they become aware of medical incompetence or unprofessional conduct. These new rights and responsibilities take effect April 1, 2022.2
Provisional Licensure for Out-of-state Professionals
2021 Wisconsin Act 10 – effective March 27, 2021 – permits physicians, nurses, and other health care providers who are credentialed in another state to provide care in Wisconsin in accordance with their out-of-state credential.
To practice in Wisconsin, the provider must apply to the Department of Safety and Professional Services for a temporary license within 30 days of providing services in Wisconsin. With a temporary license, the provider may continue practicing in Wisconsin while their application is pending for a permanent Wisconsin license. Notably, the out-of-state license must be valid and unrestricted at the time of application.
Although initially adopted in response to the COVID-19 federal public health emergency, 2021 Wis. Act 10 confirmed provisional licenses are here to stay. Wisconsin Department of Safety and Professional Services (DSPS) articulated the scope and treatment of provisional licenses as follows:
A temporary credential granted under 2021 Wis. Act 10 is treated by Wisconsin law as a full Wisconsin license, credential, permit, etc. issued by the professional’s applicable State of Wisconsin professional board or DSPS. The temporary credential is subject to all responsibilities, malpractice insurance requirements, limitations on scope of practice, and other provisions that apply under Wis. Stat. §§440 to 480 to the practice of the health care provider.3
Provisional licensure leverages the credentialing review of the provider’s home state and background checks by the provider’s Wisconsin employer to get out-of-state providers into Wisconsin practice quickly. It also retains Wisconsin’s authority with respect to the permanent licensure decision.
At the same time, it may create situations where providers come to Wisconsin, begin practicing, and then subsequently have their Wisconsin practice rights revoked. The frequency of such situations in 2022 will likely inform how employers and health insurers respond to the new provisional Wisconsin credential.
Senate Bill 394 and Advanced Practice Registered Nurses
While Act 10 and Act 23 should be monitored for their implementations, 2021 Senate Bill 394 is one to watch for potential passage in 2022. This bill creates new avenues for a registered nurse to be licensed as an Advanced Practice Registered Nurse (APRN).
The APRN licensure consists of four sub-designations of advanced practice: certified nurse-midwife, certified registered nurse anesthetist, clinical nurse specialist, and nurse practitioner. In order to receive one of these designations, the nurse must have a master’s degree or higher degree from an accredited nursing program.
Additionally, APRNs must have a related national board certification (e.g., Certified Registered Nurse Anesthetist). As written, the legislation permits currently practicing advanced practice nurse practitioners (APNPs) to be licensed as APRNs without application.
Like PAs, nurses with APRN licenses would be permitted to prescribe medication without additional certification and would be empowered to delegate tasks to other health care workers. In contrast, APRN’s would not need to have a written collaborative agreement with a physician, unless one is required by their employers. However, if a particular patient’s needs are beyond the APRN’s expertise, the practitioner must consult with another health care provider or refer the patient out.
Of note, the proposed legislation would repeal and replace Wis. Stat. section 441.15, the Nurse Midwife Practice Act and Wis. Stat. section 441.16, Prescription Privileges for Advanced Practice Nurses.
Practical Takeaways
Act 23 specifically allows health plans and employers to have additional requirements for PAs with whom they have a relationship. However, given the increased responsibilities and independence of PAs, health insurers may want to review their credentialing practices for PAs and consider their inclusion in the plan’s definition of ‘Primary Care Provider.’
As supervision requirements are relaxed for PAs and APNPs and replaced with collaboration agreements, health systems and clinics that employ these providers are challenged to maintain an environment of open communication where providers are encouraged to ask for help when needed.
Many health insurers and quality-rating bodies look for a permanent Wisconsin license as one measure of a provider’s competence to render care in Wisconsin. Permanent licensure is frequently required to become an in-network provider. Like Wisconsin’s hospitals and clinics, health insurers and quality-rating agencies are challenged to keep up with the pace of change and manage access issues created by COVID-19. Wisconsin’s Office of the Commissioner of Insurance (OCI) “requests that all health insurers refrain from making any coverage determinations based solely on the fact that a health care provider is operating under temporary licensure. OCI also requests that health insurers not refuse to add a health care provider to its network based solely on the fact that the health care provider is operating under a temporary license.”4
Advocates for improved access to medical care often point to the doctor shortage, cost and length of medical school, and physician attrition as barriers to timely and affordable health care. One hopes greater delegation and empowerment of providers at PA and APRN levels and expansion of licensure for out-of-state professionals will address shortages and have a positive effect on access to care for Wisconsinites.
This article was originally published on the State Bar of Wisconsin’s Health Law Blog. Visit the State Bar sections or the Health Law Section web pages to learn more about the benefits of section membership.
Endnotes
1 Wis. Stat. § 448.975(2)(a).
2 Wisconsin Legislative Council Act Memo, 2021 Wisconsin Act 23.
3 Information For Temporary 2021 Wis Act 10 Credential Application For Health Care Providers Licensed In Another State, Wisconsin Department of Safety and Professional Services, Jan. 4, 2022.
4 Credentialing of Temporary Licensed Health Care Providers Pursuant to 2021 Wis. Act 10, Mark Afable, Commissioner of Insurance, Dec. 2, 2021.
