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Anesthesiology/CRNA Supervision in Alabama


Mike MacKinnon MSN CRNA wrote at 2014-03-23 17:46:09

I wanted to add to this answer for clarity.

You asked if CRNAs have to be supervised in Alabama.

First, lets define what "supervision" means. There are 2 types of definitions:

1) Practice Supervision: A practitioner who requires someone who is legally responsible for and directs their practice.

2) Billing Supervision: The Billing term supervision which neither requires an individual be directed nor does it confer liability upon the "supervisor".

There is no federal law which states that all CRNAs must be practice supervised. Period.

Centers for medicare Services (CMS) requires for hospitals to bill medicare Part A CRNAs must be 'supervised'. But what does that mean?

When anesthesia is performed by an anesthesia provider on a medicare patient (this CMS law does not apply to any other insured patients), the hospital gets reimbursed for things such as supplies, equipment, drugs etc. used in the anesthetic through what is called medicare part A. This is separate from how I am paid by medicare which is Medicare part B. The Conditions of participation (COPs) for a hospital to bill and get reimbursed for their medicare part A billables related to anesthesia in a CRNA only practice states the CRNA must be 'supervised'. However this is a billing supervision NOT a practice supervision. So what does that entail?

In order for a hospital to meet COP to bill medicare part A and get their money they SIMPLY have to have the operating practitioner (dentist, podiatrist, physician) to order anesthesia BY CRNA. That is it. They do NOT incur liability for the actions of the CRNA anymore than they would if it was an Anesthesiologist NOR do they have the authority to dictate the practice of anesthesia to the CRNA. CMS recognizes the CRNA as the EXPERT in anesthesia in these cases.

So, when you ask if CRNAs are supervised it isnt a simple answer. It is complicated. The federal rule for CMS billing of medicare patients ONLY requires that for the hospital to get paid for their equipment use etc. via medicare part A that they have what i described as supervision. However, EVEN if they did not meet this requirement there are no legal ramifications and the CRNA can STILL bill medicare part B for services.

Over and over this gets confused with the idea of practice supervision which is what everyone understands but it just isnt the case. There is no requirement federally for practice supervision.

If the state "opts out" then the hospital is no longer required to meet the need for BILLING supervision. This is NO WAY effects practice of a CRNA or how it operates.

In Alabama there are thousands of CRNAs who work fully autonomously without practice supervision everyday.

For reference in regards to physician liability working with CRNAs there are tuns of legal opinions and case law showing that a surgeon is NOT more at risk working with a CRNA only in either an opt out or non opt out state than they would be working with an anesthesiologist. Even the American Society of Anesthesiologists agreed when their legal counsel stated this:

ASA Newsletter December 2000 Vol. 64 #12

“The controlling factor in determining whether a surgeon is to be help accountable for a nurse anesthetists actions is whether, based on the facts of the case, the surgeon actually exercised control or had the right to exercise control over the nurse anesthetist during the surgical procedure.”

“If not, the surgeon is likely NOT to be held accountable for the actions of the nurse anesthetist or adverse patient outcomes resulting tom the administration of anesthesia”

I hope this is much more clear now.

Mike MacKinnon MSN CRNA (another expert here on allexperts)


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Dino Kattato MSNA CRNA


Former ICU/ER RN with several years of experience. I can answer questions relating to the CRNA education process, professional issues involved, as well as questions about adult and pediatric clinical anesthesia.


Level I regional Trauma center dealing with simple to complex patient populations of all ages. Experience with general anesthesia, spinal and epidural anesthesia, and total IV anesthesia for all surgical specialties including neuro, ortho, general surgery, vascular, electrophysiology, and VIR, with the exception of cardiac anesthesia. Ambulatory surgery center dealing mostly with ENT, plastics, and eyes (70%:30% peds:adults).


AANA Journal February 2010 Feb;78(1):24-7.


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