Why Medical Claims Auditors Should Embrace Autonomy for Non-Physician Qualified Providers
Embracing Provider Autonomy: A Smarter Approach to Medical Claims Auditing
Written by: Jeana M. Singleton, Esq. | Brennan, Manna & Diamond, LLC
As the U.S. healthcare landscape continues to evolve, so too must the perspectives of those who safeguard its financial integrity, including those working in the medical claims auditing space. One of the most significant shifts in modern healthcare delivery is the growing autonomy of non-physician qualified providers (NPQPs), such as nurse practitioners (NPs), physician assistants (PAs), certified nurse midwives (CNMs), and clinical nurse specialists (CNSs). For auditors, this trend presents both a challenge and an opportunity: to adapt auditing practices in a way that reflects current care models, encourages system efficiency, and upholds regulatory compliance.
Understanding the Shift Toward Autonomy
Historically, NPQPs operated under strict supervision from physicians, often with limited billing privileges or highly constrained scopes of practice. Over the past decade, however, there has been a national push to expand the autonomy of these providers, especially in states facing primary care shortages or rural healthcare access issues. As of 2025, over half our states grant full practice authority to nurse practitioners, with many more reducing barriers annually.1
For medical claims auditors, this shift means that reviewing claims based on traditional assumptions, such as the necessity of a supervising or collaborating physician’s involvement, may no longer be appropriate or accurate in many jurisdictions. Embracing NPQP autonomy requires not only updated knowledge of scope-of-practice laws by state but also a re-examination of billing structures, coding documentation, and medical necessity standards.
Why Autonomy Matters for Healthcare Delivery
The expansion of autonomy is rooted in a growing body of evidence showing that NPQPs deliver high-quality care, particularly in primary care, chronic disease management, and preventive services. Multiple peer-reviewed studies and policy evaluations have confirmed that outcomes for patients treated by autonomous NPs or PAs are comparable to those seen by physicians, often with higher patient satisfaction and lower costs.2
From an auditing standpoint, these improvements in access and efficiency can translate to fewer unnecessary emergency department visits, better management of chronic illnesses, and a more consistent application of evidence-based care; all of which reduce the volume and complexity of avoidable claims. Supporting NPQP autonomy aligns with the broader healthcare goals of value-based care, which auditors are increasingly tasked with evaluating.
Key Considerations for Auditors
- State Scope of Practice Laws Matter:Each state’s licensing board sets specific guidelines on what NPQPs are authorized to do independently. Auditors must be well-versed in these rules to determine whether services billed are within the provider’s lawful scope. Denials or flags based on outdated or incorrect assumptions about supervision requirements can create unjust payment delays and provider friction.
- Incident-To and Direct Billing Compliance: In states where autonomy is still partial, auditors must distinguish between “incident to” billing (where services are billed under a physician’s NPI) and direct billing by the NPQP. Errors in this area are among the most frequent audit findings. In fact, one position is that NPQPs should rarely (or never) be billed “incident to” due to the number of requirements that must be met and which are unlikely to be met if an NPQP is practicing to the full scope of their license. Expanding autonomy simplifies these billing pathways and reduces the risk of non-compliant claims.
- Documentation Standards Remain High: Regardless of provider type, auditors should continue to hold all practitioners to rigorous documentation standards. Autonomy does not imply reduced accountability; rather, it heightens the need for clear, defensible clinical rationale in chart notes, diagnostic coding, and procedural justification.
- Value-Based Metrics Are Aligned: NPQPs are often more accessible and time-flexible than physicians, which can improve continuity of care and reduce patient attrition, key metrics in many value-based payment models. Claims data reflecting consistent follow-ups and fewer readmissions should be interpreted in context, as these may indicate high-performing NPQPs rather than overutilization.
The Path Forward
For medical claims auditors, the growing independence of NPQPs is not a disruption; it’s an opportunity. By staying current with provider roles and evolving scope-of-practice frameworks, auditors can better distinguish between legitimate claims and true compliance risks. This knowledge not only protects payers from overpayments or fraud but also supports healthcare systems that are more flexible, scalable, and responsive to patient needs.
Moreover, embracing NPQP autonomy can foster better collaboration between auditors and providers. When auditors understand that autonomy reflects state-level authorization and evidence-based outcomes, not a deviation from standard care, it promotes mutual trust and shared goals.
Conclusion
Healthcare delivery is no longer physician-exclusive and hasn’t been for years. Non-physician qualified providers are increasingly at the frontlines, delivering care that is accessible, cost-effective, and aligned with modern patient needs. For professionals in the medical claims auditing space, recognizing and embracing this evolution is essential. Not only does it improve the accuracy and fairness of audits, but it also reinforces the auditor’s role as a vital stakeholder in advancing high-quality, sustainable healthcare.
If you have any questions regarding NPQP practice, please don’t hesitate to contact BMD Health Law Group Member Jeana Singleton at jmsingleton@bmdllc.com or 330-253-2001.
About the Author: Jeana Singleton
Jeana Singleton has a national healthcare law practice focusing on healthcare operational matters, including state and federal regulatory compliance, healthcare transactions, healthcare policy, public health initiatives, corporate law, and business-legal strategy.
