With a Focus on Evolving Nurse Practitioner Categories
Advanced practice providers—nurse practitioners (NPs) and physician assistants (PAs)—play an integral and beneficial role in delivering patient care.
Over the last several years, there have been significant changes impacting how NPs can deliver care in California.
If you work with advanced practice providers —particularly NPs—in your practice, now is an opportune time to take a fresh look at your arrangements to ensure that they are practicing within their scope and under appropriate levels
of supervision and collaboration.
Nurse Practitioners Gain Greater Independence
NPs seeking to practice more independently can now do so through two new categories: 103 NPs and 104 NPs. Many physicians may already be working with 103 NPs who gained certification in 2023. 104 NPs, who have increased levels of independence, are expected to come on the scene this year. How might this impact physicians? Let’s first review how these categories of NPs evolved and understand how and in what settings they can practice.
Background: The Road to Independent Practice
In general, NPs in California can only practice under physician supervision and written standardized procedures¹ developed collaboratively between the NP and the supervising physician. Standardized procedures allow advanced practice nurses to provide care that is considered the practice of medicine. This is how physicians are accustomed to working with NPs.
In 2020, California Assembly Bill 890 created the new 103 and 104 categories of NPs.² These NPs are authorized to do the following without written standardized procedures: conduct advanced assessments; order, perform, and interpret diagnostic tests; establish primary and differential diagnoses; prescribe, administer, dispense, and furnish medications (including controlled substances); make referrals; certify disability for state benefits; and delegate tasks to a medical assistant. Practice areas include family/individual; gerontology; pediatrics; women’s health; and psychiatric/mental health.3,4,5
How It’s Unfolded for 103 NPs (1/1/2023 – Present)
The California Board of Registered Nursing (BRN) started accepting applications for 103 NPs in 2023. Eligibility requires the NP to complete a “transition to practice”: three full-time equivalent years (or 4,600 hours) in clinical practice as a certified NP within
five years of applying for 103 status.4,5
Certified 103 NPs can practice without written standardized procedures in group settings (e.g., clinics, hospitals, and medical group practices) with one or more physicians.5 The intent is to practice collaboratively. 103 NPs practicing in a group setting must refer a patient to a physician if the situation is beyond their education and training.5
Now It’s Time for 104 NPs (Effective 1/1/26)
Just as we saw the first wave of 103 NPs in 2023, we can expect the first group of 104 NPs to begin practicing in 2026. A 104 NP must meet all the eligibility requirements of a 103 NP, plus having practiced as an NP for three years outside of the “transition to practice” period required for 103 NPs.5,6 Certified 104 NPs are not limited to working in a group setting; however, they are required to consult with a physician according to “individual protocols” when they encounter certain situations, including: emergent conditions needing prompt medical care after stabilization; a problem that is not resolving after ongoing management; history, physical, and labs in conflict with clinical impression; or if the patient requests physician consultation.5,7 104 NPs are also required to have a plan for referring complex medical cases and emergencies to a physician.5,8
Attestation of NP Transition to Practice Hours
Nurse practitioners applying for 103 certification must have one or more providers (a physician, NP, or 104 NP) who oversaw their work attest to their completion of transition to practice hours. The attestor is only verifying that the NP has completed the required number of hours. The attestor does not offer an opinion on the NP’s competence. Attestation should be based on review of objective information rather than memory. Providers are immune from liability for attesting or refusing to attest to the NP’s hours, unless their attestation is fraudulent.4,9,10
Consultations
The physician’s role in working with 103 and 104 NPs will shift from a supervisory to a consultative one. Some communications, such as consultations requested by a 104 NP, might be more analogous to collaborating with another physician. If a consultation is presented as informal or “curbside,” remember that these can be beneficial to patient care and professional relationships, but they should also be approached with care and caution to avoid perception of a physician-patient relationship. For risk management tips on curbside consultations, see CAP’s “Curbside Consultations: What the Practitioner Should Know” at: https://www.capphysicians.com/articles/curbside-consultations-what-prac…
Non-103/104 Nurse Practitioners and Physician Assistants
The primary patient safety and liability risk for physicians working with NPs and PAs is lack of demonstrated supervision or collaboration. Malpractice actions against an NP or PA can extend to the supervising physician (i.e., vicarious liability for the NP’s or PA’s diagnosis error, improperly performed procedure, failure to treat/refer, or delayed treatment).
If an NP or PA is delivering most, if not all, care to the patient, it may create a perception of distance between the physician and patient. This can occur when the physician and NP or PA have structured their arrangement to give the NP or PA a high level of autonomy, or perhaps when a contractual agreement between an entity and physician designates the physician as supervisor for an NP or PA, but the physician does not interact with the other provider or their patients. When a poor clinical outcome occurs, physicians are surprised to learn that they may have ultimate responsibility for patient care provided by that advanced practice provider.
Written standardized procedures and collaborative agreements specify the medical care that NPs and PAs can render, and the circumstances in which they need to elicit physician input or direction. They set forth how physicians are to conduct their supervisory roles, including availability, communication, and chart review. These mechanisms help bridge distance and foster partnership.
In Closing
It is essential that physicians stay current on and understand the laws and regulations governing their supervisory or collaborative duties relative to advanced practice providers. Review your standardized procedures and collaborative agreements with these colleagues every two to three years, or when personnel or duties change. If you work with 103 or 104 NPs, do so in a way that supports sound patient care. Applying these principles to your practice promotes safety and quality, and minimizes risk.
Check with your medical professional liability carrier if your current coverage extends to these new types of advanced practice professionals.
Jane Mock, CPHRM, is a Senior Risk Management & Patient Safety Specialist. Questions or comments related to this article should be directed to JMock@CAPphysicians.com.
¹California B&P Code §§2725; 2835.7
²California B&P Code §§2837.100–2837.105
³California B&P Code §§2837.103(c); 2837.103.5; 2837.104(b)(1)
4California Senate Bill No. 1451
5California Medical Association (CMA) Legal Counsel. On-Call Document #3005.
Nurses. January 2023.
6California B&P Code §2837.104
7California B&P Code §2837.104(c)(2)
8California B&P Code §2837.104(c)(4)
9California B&P Code §2837.103(a)(1)(D)(iv)
10California Academy of Family Physicians (CAFP). Issue Brief. Nurse Practitioner Independent Practice Provider Attestation. February 29, 2024. Available at: https://www.familydocs.org/wp-content/uploads/2024/03/24.-ADV.-CAFP-Iss… (Accessed: 2/24/26)