Why PA Agreements Aren’t “Set It and Forget It”

National PA Week (October 6 – 12) is an opportunity to recognize how integral physician assistants (also known as physician associates) have become to patient care. It’s also a good time for practices to pull out a document they may not have looked at since a PA was hired: the written collaborative agreement. Does the agreement description match your operational workflow?

The biggest problem with a collaborative agreement may not be how it was drafted, but what typically arises after it’s signed. Medical practices rarely stand still. A PA may assume additional responsibilities, begin working at another location, or add new procedures. A physician may leave the practice. What once happened through daily, in-person interaction may now happen by phone or electronically.

None of those developments necessarily creates a problem. But over time, small operational changes can create a gap between the practice described on paper and the practice that actually exists.

Requirements vary from state to state, but most PAs practice pursuant to a written collaborative agreement with a physician. Intended to describe the working relationship, including the categories of care, treatment, or procedures the PA will provide, the agreement needs to keep pace with the relationship it describes.

Collaboration Isn’t Always Supervision

Illinois law describes the PA-physician relationship in terms of “collaboration,” not traditional physician supervision. Illinois law does not generally require the collaborating physician to be physically present while the PA provides care, but the physician must be available for consultation.

Yet “supervision” persists in employment agreements, job descriptions, billing policies, hospital rules, and everyday conversation. And in some contexts, it has a very specific meaning.

Medicare is an important example. Certain services performed by a PA or other qualified practitioner such as an APRN may be billed “incident to” a physician’s services if Medicare’s requirements are satisfied. The physician must have performed the initial service and remain actively involved in the patient’s course of treatment, and the service generally must be furnished under direct supervision.

Beginning in 2026, CMS permanently allowed direct supervision for many applicable services to be provided through real-time audio and video technology rather than requiring physical presence in the office suite. But other incident-to billing requirements still apply.

In other words, “collaboration” under Illinois licensing law and “direct supervision” for Medicare billing are not interchangeable.

How Compliance Gaps Arise

The gap between an agreement and actual practice rarely appears all at once. A PA may be trained to provide a new service, but no one thinks to revisit the agreement. A physician departure may result in redistributed responsibilities. 

Illinois generally permits a physician to collaborate with up to seven full-time-equivalent PAs, subject to statutory exceptions including hospitals, hospital affiliates, ambulatory surgery treatment centers and FQHCs. But even within that limit, can the physician adequately provide the collaboration contemplated by the agreement?

Billing practices can drift, too. A practice may continue billing certain PA services incident to a physician without asking whether those services still satisfy Medicare’s requirements.

Even departures can create loose ends. Under Illinois rules, when a collaborative agreement or a PA’s employment terminates, the collaborating physician must notify the Illinois Department of Financial and Professional Regulation in writing, within 10 days.

None of these changes may seem significant on their own, which is precisely why they’re easy to overlook. The agreement stays the same, but the practice gradually changes around it.

Identify the Triggers

An annual review is a good practice, but busy operations need more than a calendar reminder to appropriately prioritize legal and compliance measures. 

Certain operational changes should serve as triggers: 

• Physician departure
• New location
• Significant change in patient population
• New procedures or responsibilities
• Change in prescriptive authority
• Meaningful change in how the physician and PA work together

The answer is not necessarily a longer agreement. The better goal is accuracy.

Practices should ask: 

• What services is the PA providing?
• Are the services within the scope of practice, knowledge, training and experience of the PA? 
• Where are they being provided? 
• How does consultation occur? 
• Has the PA’s scope of responsibility changed? 
• Does the agreement accurately address prescriptive authority, if delegated?
• How are prescribing patterns monitored? 
• Do billing practices reflect the level of supervision actually being provided?

PAs should be part of that conversation. They should understand how collaboration and coverage are expected to work and whether the agreement accurately reflects their day-to-day responsibilities.

A collaborative agreement should not be an artifact of the day someone was hired. Practices change, and the agreement needs to change with them.

That may be one of the more meaningful ways to recognize PAs during National PA Week. Don’t simply celebrate the work they do. Make sure the agreements governing that work are as current as the practice itself.

For further information contact:

Aileen Kiska Brooks [email protected]