I am starting 1099 with a Telehealth company, they want me to get my DEA in Texas, my home state. I’ve been fronting everything, and will get reimbursed once I go live seeing patients.
How does it work with the collaborating physician? Do you have to make the collaborative prescriptive agreement to apply for DEA? And basically start your contract (and start paying them) while you wait for your DEA and then wait for insurance credentialing as well?
Just seems dumb to be paying for someone who isn’t doing anything for you 😑
Any insight?

I'm an MD and practice owner also working as a Supervising Physician, and I'm exploring CPAs with pharmacists where the pharmacist has authority to diagnose and treat certain conditions.

It seems like independent pharmacies, particularly in rural and underserved areas, are increasingly pursuing these agreements to expand patient access to care. I'd love to hear from physicians who have structured one of these, or pharmacists who have practiced under one. What guardrails do you use? I'd imagine things like consultation triggers, diagnosis/condition limits, prescription class restrictions, Schedule II handling, chart review cadence, etc. Would this be a liability nightmare, and what do you think are the truly necessary guardrails? Obviously the better you know the pharmacist, the more flexibility you can build into the agreement. Has anyone actually done this and would you do it again?

Per diem is becoming more popular and supervision is starting to feel less like a steady obligation and more like an on demand workload.

Traditionally, supervision fees are structured per provider based on expected oversight-things like:

• Provider experience level
• Procedure mix (risk/complexity)
• Expected chart review volume

But in reality, that oversight demand can fluctuate a lot month to month. A per diem APP might barely work one month, then be close to full-time the next (coverage gaps, seasonal spikes, LOAs, etc.).

So I'm curious, would you consider a dynamic/variable supervision fee model if it were clearly defined upfront and compliant with Stark/FMV requirements?

Is anyone doing this in practice, or are most groups sticking with fixed arrangements for simplicity/compliance?

As a supervising physician, I've noticed something that seems easy to overlook with collaboration agreements. The agreement gets signed, but the real world practice keeps changing. Scope expands, new procedures get added, medication protocols shift, and patient volume increases. On paper, the agreement may still look fine, but the day to day reality can drift pretty far from what was originally documented.

I'm trying to get a better sense of how people are actually handling this?

https://preview.redd.it/pokmusguqtrg1.png?width=1878&format=png&auto=webp&s=ee6328651a9a24c5fda59ed54ae52cd01976df47

The Med Spa sector is growing and expanding rapidly. New devices and procedures are always coming out. Many RNs are curious about what they can do in a Med Spa, the answer depends on state laws and written protocols by an authorized supervisor. The answer in this post provides some guidance for RNs practicing in Florida based Med Spas.

When complications occur, regulators rarely evaluate only the injection itself-they examine the supervision framework behind it. In disciplinary investigations, boards often assess whether oversight systems were active, documented, and clinically appropriate.

Well-drafted medical director agreements should include clear clinical protocols and operational guardrails defining how delegated aesthetic services are performed.

1. Active vs. Nominal Supervision: Regulators may request documentation demonstrating real clinical oversight, including chart reviews, quality assurance processes, and ongoing supervisory involvement. Agreements should define review frequency, documentation standards, escalation pathways, and supervisor availability expectations. Without verifiable records, supervision may be viewed as merely nominal rather than substantive.
2. Supervisor Competence: Many boards expect supervising providers to maintain procedure-specific competency consistent with delegated treatments. Agreements should require training standards, continuing education expectations, and documented competence in facial anatomy, injectable techniques, and complication management-not just general medical licensure.
3. Emergency Preparedness: Clinics should maintain immediate access to appropriate reversal agents and emergency medications, along with written protocols for vascular occlusion and other adverse events. Director protocols should specify required emergency supplies, staff training requirements, and clear response workflows to ensure complications can be managed without delay.
4. Timely Complication Response: Delays in treatment escalation-whether due to unavailable medication, unclear authority, or lack of prescriber access-can become a central issue in disciplinary or malpractice review when patient harm occurs. Agreements should define response timelines, mandatory notification triggers, and when direct physician evaluation is required.
5. Good Faith Exam & Delegation Structure: Injectable treatments typically require evaluation and authorization by a qualified prescriber before RN administration under state delegation frameworks. Delegation agreements should outline Good Faith Exam requirements, documentation standards, prescribing authority, and conditions under which treatment must be deferred.
6. Director Protocol Guardrails (Operational Standards): Medical director protocols commonly establish clinical boundaries that support consistent and defensible decision-making, such as:
   1. Minimum patient age requirements
   2. Contraindication screening standards
   3. Treatment eligibility criteria and risk stratification
   4. Maximum treatment volumes or dosing parameters
   5. Required consultation for higher-risk patients or first-time procedures
   6. Cooling-off periods for elective cosmetic treatments when appropriate
   7. Informed consent and photography documentation standards
   8. Post-treatment follow-up and complication monitoring requirements
   9. Restrictions on treating certain medical conditions without prescriber clearance.
   10. Daily/weekly patient volume limits.
7. Professional Liability (Malpractice) Coverage: While requirements vary by jurisdiction, regulators and attorneys often scrutinize whether both the supervising provider and the RN maintain appropriate professional liability coverage. Individual policies-separate from clinic coverage-can help protect practitioners when supervision decisions or complication management are questioned.

Strong aesthetic practices are built not only on clinical skill, but on defensible systems of supervision, documentation, and patient safety.

Hey everyone! I'm u/collabcares, a founding moderator of r/CollaborativePractice.

This is our new home for discussions around Collaborative Practice Agreements (CPAs), supervisory physician arrangements, medical director relationships, and clinical collaboration models across healthcare. We're excited to have you join us!

What to Post

Share anything the community may find helpful or insightful, including:

• Questions about structuring CPAs or supervisory agreements

• Experiences working with medical directors or collaborative care models

• Compliance and scope-of-practice discussions

• Contract considerations, compensation structures, and workflows

• State regulation insights or operational best practices

• Professional perspectives from physicians, pharmacists, NPs, PAs, administrators, and healthcare leaders

Community Vibe

We're building a professional, respectful, and constructive space focused on education and collaboration. Diverse perspectives are welcome - thoughtful discussion and mutual respect are expected.

How to Get Started

• Introduce yourself in the comments below (role, specialty, or interest area if you'd like).

• Post something today - even a simple question can start a valuable discussion.

• Invite colleagues who work with collaborative practice or medical oversight models.

Interested in helping shape the community? We're always looking for moderators and subject-matter contributors - feel free to reach out to apply.

Thanks for being part of the first wave. Together, let's build a trusted resource for collaborative practice professionals.

Nurse Practitioners, Registered Nurses, or Physician Assistants may want to work abroad and convert their license. However, it's often possible to work overseas at a higher salary without converting your license by taking a position on a U.S. military installation as a government employee or contractor.

I was curious on what people are getting paid to be the medical director of a SNF. It is a 45 bed facility in rural Midwest. It is minimal commitment per their administration. They said about 3 hours a month for quality meetings. I already round on most of the patients there and collect my revenue through my clinic. They presented me a contract the other day and the stipend was $600 a month which seemed low. I countered with $2,000 and they acted like I was trying to rip them off. I am a board certified family physician with 17 years experience if that makes any difference in stipend amounts. I was a medical director of a VA long term care facility in North Chicago when I was an active duty physician, but I wasn’t given a stipend since it was part of my duties so I have no clue what the going rate is now.

A great post that highlights financial challenges faced when working for multiple practices as a Nurse Practitioner under a supervising physician.

Many folks see this title but might not know that the answer depends on the state.