Phoebe Gutierrez breaks down a recent Georgia Medical Board policy statement and what it means for physicians, NPs, PAs, and telemedicine companies. Learn the key compliance risks around medical direction, physician compensation, supervision requirements, and IV hydration protocols, plus practical steps to get back into compliance.
In this solo Compliance Edition of Telemedicine Talks, host Phoebe Gutierrez dives into a recent Georgia Medical Board policy statement that has many providers and companies concerned. She explains what policy clarifications from medical and nursing boards actually mean, why they’re issued, and the grace period typically granted for coming into compliance.
Phoebe covers the five core issues in the Georgia policy, with special focus on:
She emphasizes that while Georgia is not a strict corporate practice of medicine state, it enforces rigorous oversight and supervision rules. Phoebe offers clear action steps for physicians and practices currently out of compliance and shares her perspective on what future guidance might look like. This episode is essential listening for any clinician or operator involved in supervised practices, med spas, IV hydration, or telemedicine in Georgia and similar regulatory environments.
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, [00:00:00] hey, everyone. Welcome back to Telemedicine Talks. It's your host, Phoebe, and on this episode, I'm actually gonna just talk a little bit about what it means when a medical board, nursing board, state agency issues a policy statement, policy decision, policy clarification, and, what does that mean, especially if you are unfortunately out of compliance?
So for many years, this was the main thing that I did. It's one of the reasons why I really understand how you're supposed to interpret kind of rules and regulations and build operations around it, because that's what these policy memos do. They basically are saying, "We have identified enough issues or problems or confusion around our rule set that you do not even understand the intent of the law.
Therefore, we are going to release a clarification in easier words for you to understand so that you can stop violating the law." [00:01:00] So let's get into it. Telemedicine Talks: Compliance Edition. So this month, in May, Georgia put out a policy statement, and my inbox has been pretty all over the place.
The policy statement touches a bunch of different topics, but really the crux of it is there's about five key issues, all that kind of roll into do medical directors understand what the requirements are for them to actually be a medical director and a supervising physician? If they are supervising a private practice, so an NP or a PA private practice, can they actually be compensated by that NP even if that NP is using an intermediary company, like Vian Health, my company?
Or- and then also it talks about IV hydration and what it means to be able to [00:02:00] delegate, prescriptions for IV hydration and whether or not you can use a standing order. interestingly enough, I've had all angles reach out to me about this. I've had physicians reach out to me because they're supervising practices and they're confused, or they're working with multiple different platforms, ultimately,finding, this quote unquote passive income.
I've had companies reach out to me, so large telemedicine companies that, this is pretty, pivotal to their, business. They're a network that partners with independent practices. Can they still use the model that they're using? and then, of course, large companies that where IV hydration is a service and how they're staffing it and how their protocols are and all of that kind of in between.
So these three different audiences with... They're all kind of worried about different things, but ultimately they are all very much aligned in trying to address and focus on the same kind of [00:03:00] issue. So before anybody spirals on this, I wanna be very clear. When policy memos are issued, there is a grace period for you to come into compliance.
Now, if you are grossly out of compliance, they issued the policy, they've identified it, you ha- you know, there's proof that shows that you've been told about these things and throw up the middle finger and say, "Nope, I don't wanna listen to the rules. I'm... Not for me," that's where you get enter into problems.
If you are, working in a, constructive and responsible and diligent space to come into compliance,ultimately, the boards are gonna have some leniency because again, for them to even issue a policy statement such as this, there has to be enough people that are misinterpreting or misunderstanding and violating these rules.
I wouldn't say that this is time to panic, but it really is a time for you to sit back and make sure that you are complying with these different [00:04:00] things, so that you can ensure that when they start to enforce this, because I can guarantee the key reason that these policy statements are released is 'cause they are going to enforce.
They are telling you this. They are actually gonna be telling you these five things. That's exactly what they're monitoring. Exactly. That's what we did, and It creates a rubric internally for so we can audit and monitor
consistently
But back to Georgia. So this is the part that makes this whole process a little confusing.
So G- Georgia is not a strict corporate practice of medicine state. So some of the stuff when it comes to, the money flow, from the PC to the MSO, and all of that stuff, that piece is a little confusing here because in the key crux of the issue that, that they're really trying to address is can an APRN, an NP, PA actually compensate a physician?
Doesn't that kind of skew the ph- the physician's, [00:05:00] clinical decision-making? Would they be more inclined to let the NP or the PA drive the protocol process or prescribe what they wanna prescribe or have a standing order so it's a little more passive? That's the thought of a regulator. But, I wanna be, like, really clear.
Where Georgia makes up for the ownership rules, they definitely double down and have extreme strict rules on the oversight, the supervision, and the medical compliance side. So that's the layer or the lever that they're actually pulling, and so the supervisory relationship is really where, in my opinion, all this scrutiny is living, and so much of the onus, especially in Georgia, falls on the physician So that's the key issue of the first one.
The second bucket is exactly what I was just talking about. We have these relationships, but do the physicians even comply and [00:06:00] are they even complying with kind of the rules and the requirements of it? In many instances, the physicians are being compensated through third parties. So as I had mentioned, I have a, a partnership with Leo, amazing Leo, who's not on this episode, and we do this.
We help organizations find medical directors, collaborating physicians, and they operate underneath our compliant, umbrella and infrastructure. And in those instances, our, professional corporation is compensated. We're-- Through that, we then, compensate the medical directors.
What they're saying is that regardless of how you have this set up, even if you do it in the most compliant way, if the whole reason is an APRN that is paying that physician and that's how the money is flowing, you can't do it. It doesn't, allow you to. Now, if you're working for a large enterprise or,a large medical group or clinic, I guess it's [00:07:00] a little bit different, and so that's where like some of the rules are slightly adjusted, or f- you know, a little bit more gray.
Hopefully, the state will come back and clarify some of these because it-- again, it's very confusing and, a little all over the place, especially for the people that are living in it. So you mean to tell me, I as a clinician cannot contract with a physician to be an independent medical director and supervising, but a non-clinical owner can go own a practice, do all that contract with NPs and contract with phys- like it make sense.
It doesn't really, right? So in most instances, because this policy memo is not final yet, they're taking all these nuances, these confusing pieces, and they're gonna crunch it and hopefully come out with a final policy that is going to, account for some of these discrepancies or some of these things that just don't necessarily work in practice.
You have to understand, policymakers are not the ones with the boots on the ground floor. Most of [00:08:00] them have never actually operationalized some of these things. So sometimes, in theory, we try to would write a policy, and it wouldn't be until we would get so many complaints from providers, health plans, you name it, that we would actually adjust the policy because it's like, "Oh, I guess you're right," right?
We can't require you to do something within this timeframe, and it doesn't even allow for the appropriate, handoff.
So in Georgia, Georgia actually has some really clear and specific rules of what it means to be collaborating and supervising a practice and partnering with an APRN. So under, the Georgia nurse protocol framework, a physician can, partner, but they have to be in the same specialty, specialty area or field.
they have to also always have a compliant nurse protocol. They have to submit that protocol actually to the board, and it has to get
approved ,
and the physician has to [00:09:00] remain available for immediate consultation. if they aren't, they always need to have kind of a backup identified. That all needs to be in the contract.
and also this is where it gets like hard, right? There's supposed to be direct onsite observation of the practice at least annually. When you're starting, I think you're actually even supposed to attest that you have witnessed them doing the procedure 10 times. you conduct a quarterly medical record review, so that's your typical chart review.
you ensure that the delegated acts are within the scope of practice of the APRN, of course. and you are... Again, there's a bunch of other things, but you are confirming all of those things. But on the physician side, the physician is supposed to, as mentioned, be in the same specialty, do some onsite visits, submit that agreement to the board, maintain that agreement, and then has ongoing activities that they're supposed to be complying with
So one of the [00:10:00] things that they're, in this statement that they're also saying, and they've actually monitored. I know a f- a couple physicians who've actually gotten phone calls from the board asking questions about their collaborative practice agreements and some of those things.
but some of the other things that, that,in regulation, in statute, the physician is also supposed to have an active practice within the state or be within 50 miles of that practice. And so my thought in this is that they're identifying, third-party companies being used, physicians that don't live in Georgia, physicians that, are practicing elsewhere that don't understand the Georgia rules, and they're partnering with these different clinics, which again, is opening it up to, unsafe, practices potentially due to the lack of oversight.
And so part of this is, one, they're clarifying these rules. These are not new. The amount of physicians that reach out to me and are like, "Hey, I wanna do this thing in Georgia," and I'm like, "Nice, you do not qualify." You don't. If [00:11:00] you are a physician and you have a, a practice that does mental health in Georgia and you live in Tennessee and do emergency medicine, you are not in compliance.
and I think that's really what they're trying to clarify here The third big piece is this IV hydration, call-out. But again, if you look at the layers of how they're covering this, the third bucket is you cannot just have standing orders. So as a physician who is delegating care down and down and down, typically what happens in IV hydration is it's delegated to an APRN, then it's delegated to an RN, then it, it's delegate and continue delegate.
and what they're really trying to say here is for each of those, IV hydration orders, technically there, there still needs to be that good faith exam, which again, most of the companies do and have in process. But the clinician is supposed to determine the IV hydration cocktail, not the patient.
The patient [00:12:00] shouldn't be able to go to a menu and say, "I want the hangover cure, 350, and can you throw in some of this, and can you throw in some of that?" That is not the way that it's supposed to be. There's supposed to be a general kind of intake process. That patient is assessed. That patient is guided by the clinician.
The clinician determines medical necessity. The clinician places that prescription. It is personalized. It is made for them. That is what they are really trying to emphasize here. that one is probably the clearest. But again, if you have a crack in your infrastructure, which Georgia really highlighted, they're basically saying an APRN cannot be above a physician a physician has to control, that piece.
And in order for a physician to do that, the physician has to meet all these different requirements and also comply with all of these different rules, including establishing, protocols and overseeing these providers. And we have providers that are using standing orders, and that goes against our guidance [00:13:00] and our policy.
So in sum, that is what my inbox has been littered with. So if you are out of compliance, there's a couple things that you can do. The first is if you are in Georgia and you are practicing and you go to the medical board and you look up your supervisory agreements and the physician doesn't have your names listed, and if you're a physician and you've never done this process, you're also out of compliance if you have collaborations.
that's the first thing you really need to fix. You were supposed to report this to the board before you even started practicing. So that's step one. If you are a physician who has an active collaboration in Georgia and you are not actively practicing in Georgia, I would definitely recommend terminating those agreements because you are out of compliance.
And I can tell you, I have physicians who have already received phone calls from the board [00:14:00] clarifying, "Where do you live? Where are you practicing? How did you get into this agreement?" They're prying. They're slowly starting to do what I'm gonna say is like laying that ground level to start some enforcement actions.
Third is if you... let's say you comply, you have a Georgia practice. you're w- working with a, an, a corporation. You're able to get compensated. it's not the APRN compensating the physician, but you have standing orders. You wanna change that, especially if you're doing something in the med spa aesthetic space.
You don't wanna have a standing order because, again, this letter is really clearly calling that out and saying that kind of violates what, the letter of the law. some options, as I already said, are flip it. You're going to have an IV hydration offering. It's one and done, and from there you will do your exam, you [00:15:00] will, talk to the patient, and the provider actually gets to select and they can guide the patient through that process when
they meet .
But again, it could be a collaborative prescription, a collaborative, care plan developed together.
As always, it's in the best interest of providers and physicians to comply with all of these rules. I know they're really hard to understand. I know it sucks to have these things dropped on you and you think you understand the law and then they change it. But this is really how it's supposed to operate.
And it really is all for, patient safety. My guess is that the, Georgia Medical Board is going to be releasing some updated final guidance, especially on the compensation structure. I think that this policy statement really says that private practice is dead in the state of Georgia for NPs and PAs unless they work for a large institution, which again, still [00:16:00] makes it, you know, why would you trust a non-clinician versus a clinician who's trying to operate in a compliant framework?
So I have to assume that they're going to come out with some updated guidance that is going to probably mimic or mirror a corporate practice of medicine doctrine where the physician has to own the entity and there has to be certain checks and balances on how that all, comes together. But that's my best guess.
Definitely looking forward to hear this updated guidance on, later this week and we'll do a recap. But again, these are the things that my team at Camino helps physicians and providers and large companies navigate the nuances of how to operationalize some of these things, what to do in the event that you're out of compliance and really just how to make sure that you're making the best decisions for your license, for your business, for, your patients and everything.
Thank you all for listening to me ramble on for this past 20 minutes. If [00:17:00] you guys have any questions about this or you're impacted or struggling, feel free, shoot me an email, phoebe at telemedicine talks or phoebe at caminosg.com.