Nebraska Healthcare
Compliance Guide

Nebraska presents a moderately complex regulatory landscape for healthcare companies, balancing a commitment to patient access with stringent oversight. The state has generally adopted a pragmatic approach to telehealth, recognizing its potential to expand care, particularly in rural areas, but maintains robust requirements for establishing a proper provider-patient relationship and ensuring quality of care. Key regulatory bodies include the Nebraska Department of Health and Human Services (DHHS), which oversees various health professions boards, and the Nebraska Board of Medicine and Surgery. The business climate for healthcare operations is stable, but companies must navigate the state's Corporate Practice of Medicine (CPOM) doctrine and evolving telehealth regulations. Recent legislative actions have primarily focused on refining telehealth definitions, expanding provider types eligible to deliver services, and ensuring parity in reimbursement. For instance, Legislative Bill (LB) 384, enacted in 2023, clarified aspects of telehealth practice. While not as aggressively pro-telehealth as some states, Nebraska is not overtly restrictive, making it a viable market for compliant telehealth and traditional healthcare expansion. However, the state maintains a strong stance on professional licensure and the direct supervision of certain medical procedures, which is critical for medspas and wellness clinics. Companies must pay close attention to the specific requirements for establishing a legitimate patient relationship via telehealth, especially concerning initial consultations and controlled substance prescribing. The state's professional boards are active in enforcement, underscoring the need for meticulous adherence to all regulations. Overall, Nebraska offers a structured environment where innovation can thrive, provided it is underpinned by a deep understanding and rigorous application of its healthcare laws.

Nebraska maintains a robust Corporate Practice of Medicine (CPOM) doctrine, which generally prohibits corporations or other non-professional entities from practicing medicine or employing physicians to provide medical services. The legal basis for Nebraska's CPOM doctrine is primarily derived from common law principles and reinforced by statutes governing professional licensure and corporate formation. Specifically, Nebraska Revised Statute (Neb. Rev. Stat.) § 71-1,102.01 states that 'No person shall practice medicine and surgery, or any of its branches, without first obtaining a license from the Department of Health and Human Services.' Corporations, by definition, cannot obtain such licenses. This effectively means that only licensed individuals or professional entities (like professional corporations or professional limited liability companies) owned by licensed healthcare professionals can directly provide medical services or employ other licensed professionals to do so. Non-physicians are generally prohibited from owning entities that directly employ physicians or exercise control over the clinical aspects of medical practice. This restriction extends to other licensed professions, meaning, for example, a non-dentist cannot own a dental practice, and a non-chiropractor cannot own a chiropractic practice. The critical distinction lies in who controls the clinical decision-making and who employs the licensed professionals. Permitted ownership structures typically involve professional corporations (PC) or professional limited liability companies (PLLC) where all owners are licensed healthcare professionals of the same or a related discipline, as permitted by board regulations. For telehealth companies, medspas, dental practices, and wellness clinics, this has significant implications. These entities cannot directly employ physicians or other licensed practitioners if the entity itself is owned by non-licensed individuals or a standard business corporation. This necessitates the use of a Management Services Organization (MSO) model. Under this structure, the MSO (a non-professional entity) handles the administrative and non-clinical aspects of the practice (e.g., billing, marketing, facilities, equipment, non-clinical staff), while a separate, compliant professional entity (PC or PLLC owned by licensed providers) employs the clinicians and delivers the medical services. The MSO then contracts with the professional entity to provide management services. It is crucial that the MSO does not interfere with the professional judgment of the licensed practitioners, does not engage in fee-splitting for professional services, and does not exert control over clinical decisions. Any arrangement that appears to circumvent the CPOM doctrine by allowing a lay entity to control professional practice or share in professional fees will likely be scrutinized and deemed illegal. The Nebraska Board of Medicine and Surgery has consistently upheld these principles, emphasizing that the integrity of the physician-patient relationship and the independence of clinical judgment must be preserved.

Nebraska has established a clear framework for telehealth, allowing for the establishment of a provider-patient relationship via telehealth, provided certain conditions are met. The primary statute governing telehealth is Neb. Rev. Stat. § 71-8501 et seq., which defines 'telehealth' as the use of electronic information and communication technologies to provide health care services, including assessment, diagnosis, consultation, treatment, education, care management, and self-management of health care, over a distance. A valid provider-patient relationship can be established through telehealth without a prior in-person examination, provided the standard of care is met. This is a crucial point for telehealth companies, as many states require an initial in-person visit. Nebraska does not impose such a blanket requirement, but the practitioner must ensure that the technology used is sufficient to meet the standard of care that would apply in an in-person setting. Permitted modalities include real-time interactive audio and video communication. Asynchronous (store-and-forward) technology is also permitted, but it must be sufficient to establish a diagnosis and treatment plan, and the practitioner must be able to interact with the patient as needed. Audio-only telephone calls are generally considered telehealth if they meet the standard of care and are used in a manner consistent with other telehealth modalities, especially for follow-up care or in situations where video is not feasible. However, for initial assessments or complex diagnoses, video is often preferred or required to meet the standard of care. There are no specific telehealth registration requirements for providers beyond their standard professional licensure in Nebraska. However, out-of-state providers must be licensed in Nebraska to provide telehealth services to Nebraska patients, unless they qualify under specific interstate compacts. Informed consent is a mandatory component of telehealth services in Nebraska. Prior to providing telehealth services, the healthcare practitioner must obtain informed consent from the patient, which includes informing them of the nature of telehealth, its potential benefits and risks, and their right to withdraw consent at any time. This consent must be documented in the patient's medical record. There are generally no geographic restrictions within Nebraska for telehealth services; providers licensed in Nebraska can offer services to patients located anywhere within the state. However, providers must be mindful of their own physical location and ensure they are practicing within the scope of their license and the laws of the state where they are physically located, in addition to Nebraska law.

Nebraska's prescribing rules for telehealth, particularly concerning controlled substances, are stringent and align with federal regulations. Generally, a practitioner may prescribe controlled substances via telehealth only if a valid practitioner-patient relationship has been established and the prescribing is consistent with the standard of care. For Schedule II controlled substances, the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 generally requires an in-person medical evaluation before a prescription can be issued. However, the COVID-19 public health emergency (PHE) waivers temporarily allowed for prescribing Schedule II-V controlled substances without an initial in-person exam via telehealth. As of November 11, 2023, the DEA's proposed rules for prescribing controlled substances via telehealth after the PHE indicate a return to a more restrictive approach, with some exceptions for buprenorphine for opioid use disorder and a 30-day supply of Schedule III-V non-narcotic controlled substances after an initial telehealth evaluation. Practitioners must adhere to both federal DEA regulations and Nebraska state law. Nebraska Revised Statute § 71-8507 specifically addresses prescribing via telehealth, stating that a practitioner may prescribe, dispense, or administer a drug or device through telehealth only if the practitioner has established a valid practitioner-patient relationship and has complied with all applicable federal and state laws and rules. This includes the requirement for a physical examination where necessary to meet the standard of care. For all controlled substances, the practitioner must verify the patient's identity and location. The Nebraska Prescription Drug Monitoring Program (PDMP), established under Neb. Rev. Stat. § 71-2454, requires all prescribers of Schedule II-IV controlled substances to register with and utilize the PDMP. Before prescribing or dispensing a Schedule II-IV controlled substance, a prescriber must review the patient's PDMP history. This is mandatory for both in-person and telehealth prescribing. There are no specific quantity or refill limitations unique to telehealth prescribing beyond those that apply to in-person prescribing under state and federal law. However, practitioners must exercise professional judgment and adhere to the standard of care. Special rules apply to specific drug classes. For example, GLP-1 agonists, while not controlled substances, require thorough patient evaluation and monitoring. Testosterone and other hormone therapies, often involving controlled substances, necessitate careful assessment and adherence to prescribing guidelines. Stimulants (Schedule II) are subject to the strictest controls, typically requiring an in-person evaluation for initial prescriptions, though temporary federal waivers may impact this. Practitioners must ensure their telehealth platform and practice protocols support compliance with all these requirements, including secure electronic prescribing (EPCS) and proper documentation.

Nebraska's scope of practice for mid-level providers, particularly Nurse Practitioners (NPs) and Physician Assistants (PAs), reflects a trend towards greater autonomy while maintaining a framework of collaboration or supervision. For Nurse Practitioners, Nebraska does not grant full practice authority in the sense of completely independent practice without any supervisory or collaborative relationship. Neb. Rev. Stat. § 38-2309 defines the scope of practice for advanced practice registered nurses (APRNs), including NPs. While APRNs are authorized to diagnose, treat, and prescribe, they must do so within a 'collaborative practice agreement' with a physician. This agreement outlines the scope of collaboration, consultation, and referral. The specific requirements for these agreements are detailed in regulations promulgated by the Nebraska Board of Nursing. The collaborative physician is not required to be physically present but must be available for consultation. For Physician Assistants (PAs), Neb. Rev. Stat. § 38-2022 outlines their scope of practice, which is defined by their supervising physician. PAs must practice under the 'supervision' of a licensed physician, meaning the physician is responsible for the PA's actions and must be available for consultation. The degree of supervision depends on the PA's experience, education, and the complexity of the medical services. While a PA can perform many medical tasks, including diagnosing, treating, and prescribing, these actions are ultimately delegated by and subject to the oversight of their supervising physician. There are specific rules regarding the number of PAs a physician can supervise simultaneously. Other mid-level providers, such as Certified Registered Nurse Anesthetists (CRNAs) and Certified Nurse Midwives (CNMs), also have defined scopes of practice under the APRN statutes, often requiring collaborative agreements. For medspas, the delegation rules for medical assistants (MAs) and other unlicensed personnel are critical. While MAs can perform certain administrative and clinical support tasks, they cannot perform procedures that constitute the practice of medicine or nursing unless specifically delegated by a physician or other licensed practitioner and performed under direct supervision. Procedures like injectables (e.g., Botox, dermal fillers), laser treatments, or IV therapy must be performed by a licensed physician, NP, or PA, or delegated to a qualified licensed professional (e.g., RN) under appropriate supervision. Direct supervision generally means the supervising practitioner is on-site and immediately available. The Nebraska Board of Medicine and Surgery and the Board of Nursing rigorously enforce these delegation and supervision requirements, making it essential for medspas and wellness clinics to have clear protocols and ensure all staff operate strictly within their legal scope of practice and under proper supervision.

Navigating business structuring in Nebraska for healthcare companies requires careful attention to the Corporate Practice of Medicine (CPOM) doctrine and fee-splitting prohibitions. The most common compliant structure, especially for telehealth, medspas, and other multi-state healthcare businesses, is the Professional Corporation (PC) – Management Services Organization (MSO) model. Professional Corporation (PC) / Professional Limited Liability Company (PLLC): To comply with CPOM, the entity directly providing medical services (e.g., employing physicians, NPs, PAs) must be a professional entity, such as a PC or PLLC. In Nebraska, these entities must be owned by licensed healthcare professionals. For example, a medical PC must be owned by physicians licensed in Nebraska. This entity holds the necessary state licenses to practice medicine and employs or contracts with the licensed providers who deliver patient care. Management Services Organization (MSO): A separate, non-professional entity (e.g., a standard LLC or C-Corp) acts as the MSO. This MSO provides all the non-clinical administrative and management services to the PC/PLLC, such as billing, scheduling, marketing, IT, facilities, equipment, and non-clinical staff. The MSO charges a fair market value fee for these services to the PC/PLLC. It is critical that the MSO does not dictate clinical decisions, employ licensed providers who perform clinical services, or engage in fee-splitting. Fee-Splitting Rules: Nebraska has strict prohibitions against fee-splitting, which generally means a licensed professional cannot share a percentage of their professional fees with an unlicensed entity or individual. Management services agreements (MSAs) between the MSO and PC/PLLC must be structured carefully to avoid any appearance of fee-splitting. The MSO's compensation should be a fixed fee, a percentage of gross revenue (if carefully structured to avoid linking to professional services), or a per-patient fee, but it must always reflect fair market value for the services rendered and not be tied to the volume or value of referrals or professional services. Neb. Rev. Stat. § 38-178 prohibits certain types of remuneration for referrals. Management Services Agreement (MSA) Requirements: The MSA is the cornerstone of the MSO model. It must clearly delineate the services provided by the MSO, the compensation structure, and explicitly state that the MSO has no control over clinical decisions. The terms must be commercially reasonable and consistent with fair market value. Ownership for Compliance: For any entity directly providing professional services, ownership must be restricted to licensed professionals. For example, a dental practice PC must be owned by licensed dentists. For multi-disciplinary practices, careful consideration is needed regarding whether different professional licenses can co-own a single professional entity, or if separate professional entities are required. Understanding and meticulously implementing these structures is paramount to avoid CPOM violations, which can lead to severe penalties, including license revocation and civil fines. Legal counsel experienced in Nebraska healthcare law is essential to properly establish and maintain these compliant business structures.

Nebraska's regulatory landscape is subject to ongoing evolution, with recent legislative sessions addressing various aspects of healthcare. In 2023, Legislative Bill (LB) 384 was enacted, making several key updates to telehealth statutes. This bill clarified definitions, expanded the types of providers authorized to deliver telehealth services, and reinforced the requirement for telehealth services to meet the same standard of care as in-person services. It also addressed aspects of reimbursement parity for telehealth. Another significant area of focus has been mental health access, with several bills introduced in 2024 aimed at expanding telehealth options for behavioral health services and addressing workforce shortages. While specific bill numbers are pending final legislative action for 2024-2025, the general trend indicates a continued effort to leverage telehealth for underserved populations. Regarding compact participation, Nebraska is a member of the Interstate Medical Licensure Compact (IMLC), allowing eligible physicians to obtain expedited licensure in Nebraska if they hold a license in another compact state. This significantly streamlines the licensing process for physicians seeking to practice telehealth in Nebraska. The state is also a member of the Nurse Licensure Compact (NLC), enabling registered nurses and licensed practical nurses to practice in Nebraska with a multi-state license from their home state. There are ongoing discussions about Nebraska joining other compacts, such as the Psychology Interjurisdictional Compact (PSYPACT) and the Physical Therapy Licensure Compact, which would further facilitate interstate practice for these professions. Enforcement actions by the Nebraska Board of Medicine and Surgery and the Board of Nursing consistently target unlicensed practice, improper delegation, and violations of the Corporate Practice of Medicine. Recent cases, while not widely publicized, underscore the boards' commitment to maintaining professional standards and ensuring patient safety. Companies should monitor the legislative sessions closely for any new bills affecting telehealth definitions, reimbursement, or scope of practice, particularly those related to controlled substance prescribing, which remains a dynamic area of federal and state regulation.

For healthcare companies entering or expanding in Nebraska, a systematic approach to compliance is essential. Step-by-Step Compliance Checklist: 1. Licensure: Ensure all healthcare professionals (physicians, NPs, PAs, etc.) are individually licensed by the appropriate Nebraska board (e.g., Board of Medicine and Surgery, Board of Nursing). For out-of-state providers, leverage compacts like IMLC or NLC if applicable, or pursue full Nebraska licensure. 2. Business Structure: Establish a compliant MSO-PC/PLLC structure. The professional entity (PC/PLLC) must be owned by Nebraska-licensed professionals. Draft a robust Management Services Agreement (MSA) ensuring fair market value compensation and no clinical interference. 3. Telehealth Protocol: Develop clear telehealth policies and procedures covering patient identity verification, informed consent, documentation, emergency protocols, and technology requirements. Ensure modalities used meet the standard of care. 4. Prescribing Compliance: Implement strict protocols for prescribing, especially controlled substances. Register with and utilize the Nebraska PDMP. Adhere to federal DEA rules (including Ryan Haight Act and post-PHE regulations) and state prescribing laws. 5. Scope of Practice: Verify that all providers operate strictly within their Nebraska-defined scope of practice. For NPs and PAs, ensure valid collaborative or supervisory agreements are in place and documented. For medspas, meticulously define delegation protocols for all procedures. 6. Privacy & Security: Implement robust HIPAA-compliant privacy and security measures for all patient data and telehealth communications. Common Pitfalls to Avoid: 1. CPOM Violations: Assuming a standard corporate structure is permissible for direct patient care. Failing to properly separate clinical and administrative control. 2. Unlicensed Practice: Allowing non-licensed personnel to perform tasks outside their legal scope or without proper supervision. 3. Inadequate Patient Relationship: Prescribing or treating without establishing a legitimate practitioner-patient relationship via appropriate telehealth means. 4. PDMP Non-Compliance: Failing to register with or check the PDMP before prescribing controlled substances. 5. Fee-Splitting: Structuring MSO fees as a percentage of professional fees without careful legal review to ensure fair market value and avoid prohibited arrangements. Timeline Expectations: Licensing for individual providers can take 3-6 months. Establishing a compliant MSO-PC structure, including corporate formation and drafting MSAs, typically takes 2-4 months. It is prudent to allocate sufficient time for legal review and board inquiries.