What Medical Assistants Do
Medical assistants (MAs) are professionals who typically work in physicians’ offices, group practices, and other healthcare facilities. Their duties commonly involve both clerical and clinical tasks, depending on the type of office they are in, as well as their particular area of expertise. MAs perform a wide array of duties from updating and filing patients’ medical records, measuring vital signs, assisting with examinations, counseling patients on proper handling of their personal care, or explaining special diets or medication instructions, to arranging for hospital admission or laboratory services.
MAs may specialize in a number of areas , including podiatric care, ambulatory surgery centers, ophthalmology, dermatology, and more. In each of these settings, the employee’s knowledge of the specific healthcare field in which they work is vital to ensuring compliance with federal and state antikickback laws and regulations.
As the role of the MA becomes more essential to primary healthcare and reimbursement models, increased accountability for wrongful acts, and greater scrutiny of the industry by regulators and prosecutors, organizations and physicians must review their polices and practices to ensure that either all or only specific MAs can provide specific services.
What Is the Legal Scope of Practice?
Defining the legal scope of practice for medical assistants is complicated. For one, a medical assistant is classified differently in every state. In some, medical assistants are considered unlicensed personnel, even though they are permitted to perform noninvasive procedures under the supervision of a licensed professional. In other states, medical assistants are permitted to perform advanced duties (like in California) while in others, they are limited to only the most basic functions. In addition, the scope of a medical assistant’s role is widely different from state to state and from one healthcare provider to another. Although you may be permitted under federal or state law to perform certain tasks, your employer has the last say in what you can or cannot do in your state and/or facility. So what does it mean to be within the legal scope of practice for a medical assistant? Simply put, it means doing exactly what your job has defined for you and not dabbling in other areas. If your employer has a policy that says medical assistants must be certified in order to administer injections, then you must adhere to that policy. If your state has regulations that say medical assistants can still perform routine tests even though their state has opted out of CLIA testing, those tests must be performed in a CLIA-compliant laboratory. What Happens When Medical Assistants Go Beyond Their Legal Scope of Practice? When medical assistants perform functions and tasks for which they are not permitted to perform in their state or for the facility in which they work, they expose themselves to the following risks: If all medical assistant state and federal regulations seem overwhelming to you on your own, you may want to consider taking a course on medical assisting basics. Having solid formal training can help you navigate and understand the legal scope of medical assistants. You can even take a course that is specific to your state.
State-by-State Variations
While there is much legal overlap, Medical Assistants may not be practicing in a state that has the same licensing and certification requirements as another. From California to Virginia, Massachusetts to Oklahoma, different states have, or had, different requirements for Medical Assistants in order to perform certain duties. These discussable differences are mainly found at the state scope of practice level. An example of extreme variation of laws can be found when comparing the definition of a Medical Assistant in Nevada to the definition in Pennsylvania. In Nevada, the definition of a Medical Assistant includes the performance of certain advanced fingerstick procedures (e.g., capillary blood glucose testing, hemoglobin A1c testing, mononuclear screening, pregnancy testing). This is found in Nevada Administrative Code 630.574(3)(d) and is a procedure that appears to be outlawed in Pennsylvania. The Pennsylvania definition of a Medical Assistant appears in 49 Pa. Code §21.17(b) and boldly states "A Medical Assistant has no medical or therapeutic function." While this is a bit extreme, requirements and definitions can and do vary from state to state. Some states, like Texas, require that when any invasive procedure, whether performed by a RN or LPN, a physician must first examine the patient and order the procedure. Texas is known as a "physician-directed state" which is in contrast to most states that are considered "independent states" where a Licensed Vocational Nurse or a Registered Nurse may operate independently without physician approval. Physicians also remain licensed in all states and are governed by specific licensing requirements. Certain duties – like the performance of X-ray procedures – are limited in some states to only MDs and DOs. Certain states give non-physicians an expanded scope of practice, provided they have the appropriate supervision from a physician such as RNs and LPNs.
Commonly Allowed Duties by Law
There are a number of duties which are commonly permitted by statute to medical assistants, though differences can be found, and they should not be confused with "uniform" scope of practice. First is administrative or clerical work which permits the medical assistant to handle insurance forms, medical records, hospital admissions, and laboratory requisitions. Then, in the clinical area, are such "common" procedures as sterile and non-sterile dressing changes with attention being paid to the legal requirements concerning properly trained staff and supervision, injections (important here to realize that only one state, Wisconsin, permits the injection of local anesthesia – all others limit injections to immunizations), topical anesethics, obtaining vital signs, caring for and removing urinary catheters, fingernail trimming, nasal suctioning, the use of pulse oximeters, EKGs, audiometry, preparing, administering and monitoring medications (other than intravenous or parenteral therapies), wound packing and removal, simple skin scrapings, skin punctures, phlebotomy, venipuncture, taking samples for culture, assisting with vision tests, phototherapy, taking nasopharyngeal aspirates, endotracheal aspirates, nasopharyngeal aspirates, ear irrigation and irrigation of other orifices, throat swabs, cerumen removal, tympanogram, administering eye washes and drops, assisting with contact lenses, dressing changes, spinal board training, urine dip-stick tests and urinalysis, determining body fat percentage, performing spirometry, assist in minor surgery, interpreting a pulse oximeter and the use of nebulizers and humidifiers.
Supervision, Delegation, and Orders
As explained above, the medical assistant-side of the equation is relatively free to take on whatever scope of practice their employer deems appropriate for them. Medical assistants contribute to the healthcare team in working with patients and their families in all aspects of care. Medical assistants, however, are not licensed individuals. Thus, it is critical that their job responsibilities always include supervision by a licensed healthcare provider. This applies even though most tasks undertaken by medical assistants fall well within their scope of practice.
This means that in the employment context, the physician can always require the medical assistant to work under the direct supervision of a licensed healthcare provider. In certain contexts such as hospital settings, this means that the medical assistant must work under the supervision of a physician, nurse, or other appropriate health care provider who can be present in the center where medical assistants typically work. Most employers have established policies and procedures that require the delegation of responsibility to occur only in circumstances where a physician, nurse or other licensed health care provider is either present in the room with the medical assistant or is immediately available in the clinic or off-campus facility.
For example, if an urgent care center is assessing a child with suspected strep-throat, a physician could very well ask the medical assistant to take a throat-culture swab from the patient to determine whether the child had strep-throat. A licensed nurse or physician must be within the sound of the Epic machine or the clinic waiting room or on the other end of a communicator with the Medical Assistant at all times, however, for that task to be one that is legally delegable in the state of New York. The medical assistant cannot just rely on a test result from a laboratory service that comes back later in the night to make a recommendation for treatment of the sufferring child without a healthcare provider present and supervising.
The Center for Medicare/Medicaid Services ("CMS") defines direct supervision in its Conditions for Coverage for Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services as "the procedure was ordered by the physician or nonphysician practitioner and the physician or nonphysician practitioner is immediately available to furnish assistance and direction throughout the performance of the procedure." 42 C.F.R. § 486.65(b). The physician or nonphysician practitioner is considered "immediately available if he or she is within the same room and able to begin treatment of the patient in the event of an emergency." 42 C.F.R. § 486.65(d)(1). The physician or nonphysician practitioner is considered "immediately available if he or she is within the immediate area (i . e., office suite) and, if necessary, is able to begin treatment of the patient in the event of an emergency." 42 C.F.R. § 486.65(d)(2).
For technicians or other non-physicians, CMS states that supervisory responsibilities apply in the context of laboratory tests. Apart from requesting tests and reporting or recording tests, the physician must be involved in the exercise of discretion. He must be the one who selects the test that is performed on the patient and interprets the test results. If the supervising physician delegates the task to another individual, direct supervision may apply to the delegated individual. 42 C.F.R. Part 493.1443(b)(8), 42 C.F.R. Part 493.1485(c)(7); See Preamble to CLIA Final Rule, 56 Fed. Reg. 60032-33 (Nov. 27, 1991).
Many states have similar regulations to support the supervision requirement spelled out in the CMS regulations. For example, Washington state contains regulations requiring that a medical assistant’s activities must be tied to a physician’s management authority. As explained in Wash. Admin. Code § 246-827-030: "The activities of a medical assistant must be supervised by a physician, a physician assistant, or an advanced registered nurse practitioner. Supervision includes: (a) Personally reviewing the actions of the medical assistant; (b) Specifying the function of the medical assistant; and (c) Accepting or countermanding the medical assistant’s actions or recommendations."
Although the supervision requirement is not codified by New York law, it is implicit in the practice acts of many licensed professions in New York State, particularly the practice of medicine. The New York State Education Department, Office of the Professions, issued a February 2013 "Guidance on Delegation and Supervision" and stated that "[t]he ultimate responsibility for the performance of non-licensed support personnel always rests with the licensed professional who assigns a task to be performed by, or accepts oversight responsibility for, a specific task, whether or not that task is delegated."
As stated above, the medical assistant can be tasked with work that falls within a physician’s scope of practice, but a licensed health care provider must always be supervising that work. There are many instances wherein licensed professionals can delegate responsibilities to a qualified medical assistant. The medical assisting profession itself also contains a number of specialists, including Registered Medical Assistants ("RMAs") and Certified Medical Assistants ("CMAs"). A RMA or a "C"MA provides additional certifications that a medical assistant has expertise in their specialty and is able to perform additional, delegated functions as a matter of course in their medical assisting job.
Legal Restrictions and Prohibitions
Certain limitations and restrictions are placed both by law and by the facilities that employ medical assistants, to help ensure that patient rights and safety are maintained in the performance of tasks that are permitted for medical assistants to do.
First, let’s look at a few general limitations to start. A medical assistant can’t:
· Unlawfully disclose or knowingly permit the disclosure of a patient’s confidential medical information
· Perform their duties in a facility that is not licensed by the state unless the medical assistant is performing such duties in conjunction with an accredited educational program
· Perform those duties that are prohibited under another California statute (such as an unlicensed physical therapist performing physical therapy services that can only be performed by a licensed physical therapist)
· Deliberately falsify a patient’s medical record
· Engage in criminal conduct involving ethical issues in the work environment
· Convictions for crimes that pose a substantial risk of harm to patients or other persons
· Illegally file or cause to have filed any information collected during the course of their duties that is known to be false
So what about medical assistant’s licensure? Is a certification or registration required in order to practice as a medical assistant in California? No. A medical assistant does not need to hold any form of certification to perform the duties of their profession. Therefore, the medical assistant’s scope of practice is broad. But, that does not mean that any specific medical assistant is permitted to do any task or duty that could be performed by a medical assistant. Since a medical assistant may work in a variety of different fields (such as a physician’s office, hospital or clinic), specific limitations are placed on which tasks and duties an individual medical assistant may perform depending upon their particular area of employment.
Historical Trends and New Directions
Historically, the functions of medical assistants have undergone significant change over the years. In the mid-20th century, they served mainly as administrative aides, handling recordkeeping and some billing tasks. As healthcare delivery evolved and demanded greater flexibility and more cost-effective service, their roles expanded. Today, medical assistants perform a variety of clinical tasks, which some states allow to be carried out by unlicensed personnel. The emergence of health information technology ("HIT") has further increased their clinical responsibilities. For example, over 70% of the electronic records in hospitals are now managed by medical assistants, and equipment support is often now also provided by them. HIT systems, of course, also require sophisticated use of electronic healthcare documents (such as HCFA forms), which most medical assistants have not been trained to develop, create or utilize.
Advancements in technology also affect how medical assistants enter the workforce. Historically, aspiring MAs augmented their education through on-the-job training, but schools offering online programs have become more prevalent. Certification regulations vary by state, but the majority of states have no requirements for certification, and no national certification process exists. This lack of national standardization presents challenges in determining what types of legal duties can be expected of or performed by MAs in each state. Moreover, the various national certification associations also do not have a uniform approach to licensure by the states. This is especially important because several states have laws prohibiting unlicensed personnel from performing certain healthcare services, and those laws often prescribe criminal or civil penalties for violations. In short, states have developed their own legislative and regulatory prescriptions for the scope of practice for medical assistants. Whereas some states have enacted statutory or regulatory language focusing on licensure or certification, others have left it to the licensure boards to implement their understanding of the state laws. Still others have not directly addressed the issue at all. Further complicating matters is the ongoing trend of physicians and other practitioners seeking to delegate even more of their work to MAs, as well as the varying interpretations of its legality among the states. For these reasons, the question of whether MAs can legally "do more if delegated" requires consideration of the laws in each state.
Staying Legal, and Staying Current
The need for vigilance in these areas is underscored by the fact that the state laws for MAs are not static—every few years, states amend the rules and the line gets moved again. In North Carolina, for instance, the current practice act has been amended several times since being enacted in 1983. In Minnesota, a law establishing supervision and education requirements for MAs was repealed in 1998, and although there are no formal requirements, the law still specifies that task delegation be based on the knowledge and skills of the MA, who "should have received appropriate training… and be competent to perform the services they provide" (Minn. Stat. § 147A.01 et seq.).
Because the landscape is always changing , staying up to date on the rules and regulations for MAs is essential in every state. Many states maintain their own MA associations, which are a good source of information for both regulatory and educational updates. Nationally, organizations such as the American Association of Medical Assistants and the American Medical Technologists aim to support MAs through credentialing, certification, and educational resources and programs.
New practitioners can also benefit from on-the-job training and mentoring. Training should be designed to specifically address nuances in the laws and regulations that vary from state to state.