The Toughest States for Nurse Practitioners: Where Collaboration is a Nightmare

For nurse practitioners (NPs), securing a collaborating physician can be an uphill battle in certain states. Strict oversight rules, geographic restrictions, specialty-matching requirements, and mandatory in-person meetings make it difficult to find a physician willing to collaborate. These challenges not only delay practice but can also drive up the costs of securing a collaborator.

If you’re considering practicing in Alabama, Georgia, South Carolina, Pennsylvania, or Mississippi, here’s why collaboration in these states is particularly frustrating—plus additional challenges in Tennessee and Florida.

1. Alabama

Limited Physicians, Specialty Restrictions & In-Person Oversight

Alabama makes it exceptionally difficult to secure a collaborating physician due to its strict regulations and specialty-matching requirements:

• Physician Limits: A physician may collaborate with only nine NPs nationwide, making it difficult to find available doctors.
• Specialty Matching: The physician’s specialty must align with the NP’s scope of practice, making it harder to find a match.
• On-Site Oversight: Physicians must conduct quarterly, in-person visits and review 10% of patient charts monthly.
• State-Specific Licensing: The physician must be licensed and actively practicing in Alabama, meaning out-of-state doctors can’t collaborate.

➡ Regulation: Alabama Administrative Code, Rule 610-X-5-.08, Code of Alabama § 34-21-80 et seq.

2. Georgia

Proximity Limits, Face-to-Face Meetings & Specialty Rules

Georgia’s geographic restrictions and mandatory in-person check-ins make collaboration a major hurdle:

• 50-Mile Rule: If the physician is not primarily practicing in Georgia, they must be within 50 miles of the NP’s practice site.
• Quarterly In-Person Meetings: Physicians and NPs must meet in person every three months, adding scheduling and travel burdens.
• Specialty Matching: The physician’s specialty must match the NP’s area of practice, which narrows the available pool of collaborators.
• Prescriptive Authority Restrictions: NPs cannot prescribe Schedule II medications unless explicitly authorized in the agreement.

➡ Regulation: Georgia Code § 43-34-25, Georgia Administrative Code § 360-32.

3. South Carolina

In-State Physician Requirement & Bureaucratic Hurdles

South Carolina requires physicians to be licensed and residing in the state, making it harder for NPs to find eligible collaborators.

• Physician Residency Requirement: The collaborating physician must reside and be actively practicing in South Carolina, eliminating out-of-state options.
• Collaboration Agreement Review: The agreement must be available for state review within 72 hours upon request, making compliance an ongoing concern.
• Physician Ratios: A single physician can collaborate with only a limited number of NPs, meaning many are unavailable.
• Prescriptive Limitations: NPs cannot prescribe Schedule II medications unless separately authorized, adding another layer of bureaucracy.

➡ Regulation: South Carolina Code § 40-33-34, South Carolina Code of Regulations § 91-5.

4. Pennsylvania

The Backup Physician Problem

Pennsylvania presents a unique challenge—NPs must secure two physicians instead of just one.

• Backup Physician Requirement: If the primary physician is unavailable, a backup physician must step in. Finding and compensating two physicians doubles the cost and complexity.
• Prescriptive Authority: NPs must submit their collaborative agreement for approval before they can prescribe medications, adding another bureaucratic step.
• Oversight Rules: The collaboration agreement must outline detailed physician responsibilities, including oversight of NP practice, making negotiations more complicated.

➡ Regulation: Pennsylvania Code, Title 49, § 21.282a.

5. Mississippi

High Compliance Burdens & Strict Oversight

Mississippi has one of the most rigid collaborative models in the country, with extensive compliance, reporting, and geographic restrictions.

• Physician Proximity Rule: The collaborating physician must be within 75 miles of the NP’s practice location—this severely limits options for NPs in rural areas.
• Frequent Chart Reviews & Meetings: Physicians must review charts monthly and conduct quarterly, in-person check-ins.
• Bureaucratic Compliance: NPs must submit written reports to their physician collaborator, adding another layer of documentation.

➡ Regulation: Mississippi Code § 73-15-20.

Bonus: Other States with Challenging Collaboration Rules

Tennessee: Still Some Barriers Despite Loosening Rules

• Two Required In-Person Meetings Per Year: Tennessee recently reduced its requirements, but twice-yearly face-to-face meetings are still mandatory.
• Physician Ratios: A single physician can only oversee a limited number of NPs.

➡ Regulation: Tennessee Code Annotated § 63-7-123.

Florida: Specialty-Based Collaboration Rules

• Psychotropic Prescriptions Require a Psychiatrist: If an NP prescribes Schedule II psychotropic medications, they must collaborate with a psychiatrist.
• Same-Specialty Rules: Many physicians must be in the same specialty as the NP, making collaborations harder to secure.

➡ Regulation: Florida Statutes § 464.0123.

Final Thoughts: What Can NPs Do?

If you're in one of these states, finding a collaborating physician may take longer, cost more, and require extra administrative work. Here are some ways to navigate the system:

✔ Start Early: Finding a physician in restrictive states can take months. Begin your search well before you plan to start practicing.

✔ Understand the Costs: Some physicians charge high fees due to the compliance burden—factor this into your business planning.

✔ Leverage NP-Friendly Networks: Seek out professional organizations or physician groups that actively work with NPs.

✔ Know the State Laws: Being well-versed in the regulations gives you an advantage in discussions with potential collaborators.

While progress is being made in many states, these five (plus Tennessee and Florida) still impose serious challenges that every NP should be prepared for.