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Professional Practice

Terms in this set (77)

List Types of Health Insurance Plans
1. Medicare A
2. Medicare B
3. Medicare B Supplement
4. Medicare C Advantage Plans
5. Medicare D
6. Medicaid
7. Commercial PPO
8. Commercial HMO
When NPs bill under their own Medicare number,
the reimbursement is at:
85% of the physician fee
schedule
What does Medicare A cover?
1. Hospitalization costs for inpatient stays
2. Rehab facilities are usually covered but under 2 stipulations (a. Must come from Hospital setting b. Must be inpatient for at least 3 days in hospital setting)
3. Nursing home days during PT (however must be a medically necessary service and patient must SHOW PROGRESS, otherwise patient pays out of pocket)
4. Hospice
5. Home Health
Medicare A trends
1. No longer pays for 30 day readmissions for PNA, CHF, MI
2. Monthly evaluations of hospice patients to make sure patient still qualifies for hospice care
What does Medicare B cover?
1. Outpatient Costs
-Medicare pays 80%, Patient responsible for 20%
-Medically Necessary Care
-Preventive Services
2. Durable Medical Equipment
-Rules and criteria must be met (e.g. Quad cane/Walker or Diabetic wide shoe requires a diagnosis on the script e.g. DM with neuropathy)
Medicare B trends
1. Meaningful Use **NP's are not eligible for meaningful use reimbursement in MediCARE but ARE in MediCAID
-3 stages -Smoking status/Med Reg/Report of Visit/E prescribing "Attest" for use of EMR components -Bonus incentive
2. Raising age for Medicare eligibility (65 to 67)
3. PQRS Physician Quality Reporting System (moving from voluntary for bonus to a penalty for non reporting)
Medicare C (1. What is it? 2. Examples include 3. The plan must follow what guidelines 4. Practices 5. Differences in plans)
1. They are ADVANTAGE PLANS: Basically commercial insurance plans from private insurers
2. e.g. Keystone 65 or Bravo
3. The plan must follow Medicare guidelines
4. Not all plans are accepted at all practices
5. Plans are different in what they cover
Trends in Medicare C
-Medicare assigns STAR ratings to each plan (1-5, 5 being very comprehensive/good quality)
-Medicare Plan makes quality reimbursements to practices (e.g. filling out "quality" forms)
-Congressional recommendations (Paul Ryan's plan) want to make Medicare a voucher program. Recipients would get a stipend to buy a MAP product. Prone to increased costs to seniors
Medicare D (1. What is it? 2. Who is eligible 3. How is it available 4. Cost to recipient 5. Problem with)
1. The "Drug Benefit"
2. Everyone in Medicare is eligible
3. Available through Medicare, MAP or private plans
4. Pay a monthly fee
5. Donut Hole Gap (Difference between maximum allowance and catastrophic coverage threshold)
Medicare D Donut Hole (1. 2015 rates Gap vs Catastrophic Coverage 2. What are we doing about it?
1. Gap $2,960, Cat Cov $4,700
2. -Stipends currently sent to gap seniors
-Manufacturers agreed to discount drugs for seniors in the donut hole (55% Brand and 65% Generic in 2015)
-The ACA reduces the catastrophic coverage threshold annually until no donut hole exists in 2020
Medicare B Supplement (1. What are they? 2. How paid?)
1. Supplemental plans offered by Commercial Insurance (e.g. AARP); they pay the 20% that Medicare doesn't pay; They are not mandatory
2. Deductibles still apply
Commercial PPOs (1. What are they? 2. How)
1. Preferred Provider Organization
2. Fee for service
3. Bill for visits and procedures
4. Any providers within a network of the insurer
5. No referrals required
6. Prior authorizations often required
Commercial HMOs (1. What are they? 2. How do they work?)
1. Health Maintenance Organization
Managed Care:
2. Primary Care Selected
3. Capitated to a specific network
4. Usually a less costly option
5. Practices are paid a Per Member Per Month fee for how ever many "lives"/patients they have
6. Referrals are required
7. Bloodwork usually has to be done at a certain lab
Trends in Commercial Insurance
1. Value Based Purchasing or Pay for Performance
2. Paying for quality not quantity
3. Are practices meeting the standards of care?
4. Are networks meeting the standards of care? (Cardiology + PCP + Endocrine + Ophthalmology)
5. Additional stipends for Patient Centered Medical Home practices
Medicaid (1. What is it? 2. Who pays for it/Payment process? 3. Approval process 4. Can be combined in what circumstances 5. Practices and Medicaid 6. Reimbursement for NP's
1. A federal Insurance program for people with very low income (Not everyone qualifies)
2. Paid for by state and federal government (federal government gives each state $ and then the state decides how to use it; Usually administered through managed care plans (Medicaid pays $ to Managed Care Organization e.g. Keystone Mercy/Keystone First/Health Partners); States pay a stipend to the plans and plans reimburse practices pathetically...practices end up losing $
3. Usually takes a LONG TIME to be approved UNLESS pt has a e.g. renal disease (need HD right away)
4. Patients may have dual coverage e.g. 65 yo or disability + very low income
5. Limited number of practices accept these plans or practices cap the number of Medicaid patients it will accept
6. NPs are eligible for Meaningful Use attestation in Medicaid
Health Insurance Exchanges (HIX)
-Numerous products developing ("Obamacare")
-States have to OPT in (state by state basis)
-States are opting out in some cases because of cost...Federal funding at 100% until 2016, then 90% after 2016
Credentialing (What is it essentially? Who does this? What does this involve)
-Verification that you meet the criteria for practice
-Done by organizations and insurers, e.g. CMS
-Medicare ID # and NPI #
Medicare ID # and NPI # (Who assigns it and What are they used for?)
-Medicare ID# (Used for billing and reimbursement)
-NPI # (Used for all HIPAA standard transactions; Required on prescriptions)
Billing Outpatient NP Services: CMS (New patients vs Existing patients for example)
-Need a supervising physician
-Patients new to the practice must see the PHYSICIAN to meed Medicare guidelines
-Established patients (New vs Existing problem)
"Incident to" Billing
-100% reimbursement
-Need a supervising physician who is physically present at the time the services were rendered
-If THAT supervising physician has seen THAT patient for THAT diagnosis then you may bill incident to
-outpatient
-Document that Dr. ________ was the supervising physician today OR Have the physician sign your chart
Medicare "Incident to" criteria
1. Physician must personally perform the initial service and remain actively involved in the course of treatment
2. Physician must be present in the office suite
3. NPP must be directly employed by the physician, physician group or entity that employs the physician(s). NPP may also be leased or independent contractor.
4. "Incident to" applies to the office/clinic setting. "Incident to" is not applicable in the hospital setting.
Billing Outpatient NP Services: Commercial 3rd Party Payers e.g. Aetna, Blue Cross PPO (What is the prevailing type of billing? How does credentialing work? Does the physician need to be present?)
-Incident to is the prevailing type of billing
-Often leave credentialing to the health care organization
-Physician must also be physically present
What are Billing/Encounter Sheet Requirements?
1. Diagnosis (ICD 10 codes)
2. Level of Service (1-5) (CPT code)
3. Signature
Billing/Encounter Sheet: Diagnosis includes what?
1. Specific diagnosis/ICD 10 code (e.g. ABD pain RLQ)
2. Procedures
3. Time based billing (e.g. Diabetes education 40 minutes)
4. Cannot use r/o alone
Billing/Encounter Sheet: Level of Service is determined by what?
1. Items in your CC/HPI
2. Items in your ROS
3.Items in your Physical Exam
4. Complexity of medical decision making
5. Amount of time if time based billing
E&M Level 1 Established Patient Outpatient Visit (1. Includes what in History and Exam? 2. Average time 3. E&M Code)
1. History N/A; Exam N/A
2. 5 minutes
3. 99211
E&M Level 2 Established Patient Outpatient Visit (1. Includes what in History and Exam? 2. Average time 3. E&M Code)
1.
a. CC + HPI (1-3)
b. 1 Organ System
2. 10 minutes
3. 99212
E&M Level 3 Established Patient Outpatient Visit (1. Includes what in History and Exam? 2. Average time 3. E&M Code)
1.
a. CC + HPI (1-3) + ROS (1)
b. 2-7 Organ Systems
2. 15 minutes
3. 99213
E&M Level 4 Established Patient Outpatient Visit (1. Includes what in History and Exam? 2. Average time 3. E&M Code)
1.
a. CC + HPI (4+) + ROS (2-9) + PFSH (1) (PFSH=PMH/Social/Family Hx)
b. 2-7 Organ Systems + extended exam of affected areas (e.g. Peak Flow/Pulse Ox)
2. 25 minutes
3. 99214
E&M Level 5 Established Patient Outpatient Visit (1. Includes what in History and Exam? 2. Average time 3. E&M Code)
1.
a. CC + HPI (4+) + ROS (10+) + PFSH (2)
(PFSH=PMH/Social/Family Hx)
b. >/= 8 Organ Systems
2. 40 minutes
3. 99215
What Outpatient level visit is this? Code? Average time?
a. CC + HPI (4+) + ROS (10+) + PFSH (2)
b. >/= 8 Organ Systems (clarify this, notes contradict)
level 4 (99214)
25 minutes
What Outpatient level visit is this? Code? Average time?
a. CC + HPI (1-3)
b. 1 Organ System
level 2 (99212)
10 minutes
What Outpatient level visit is this? Code? Average time?
a. CC + HPI (1-3) + ROS (1)
b. 2-7 Organ Systems
level 3 (99213)
15 minutes
What Outpatient level visit is this? Code? Average time?
a. CC + HPI (4+) + ROS (10+) + PFSH (2)
(PFSH=PMH/Social/Family Hx)
b. >/= 8 Organ Systems
level 5 (99215)
40 minutes
What does CMS do?
Set the trends, private insurers often follow
Most restrictive guidelines
Medicare C: Advantage Plans (MAP)
these are Commercial insurance plans from private insurers
• They Must follow Medicare guidelines
• Not all plans are accepted at all practices
• Medicare Pays the Plan directly up to a certain amount, and then the Patient pays the difference in cost
Health Insurance Exchanges (HIX) - there are various health insurance plans available through this
• Federal funding pays for 100% of the insurance costs from 2014 to 2016
• Then Federal funding only covers 90% after 2016, and the other 10% of the insurance costs come from the states.
Used for all HIPAA standard transactions, such as electronic prescriptions

Required on all prescriptions for med or DME
NPI #
In order to bill medicare for new pt visit this must happen:
MUST be seen by a physician on the first visit
Commercial 3rd party payers:
• "Incident to" is the prevailing type of billing these 3rd party payors use
• This often means the insurance company leaves credentialing to the health care practice/organization
• Similar to Medicare, if a Dr is your supervising physician and you are billing Incident To, the Dr needs to be physically there at the time of rendering services
Billing or Encounter Sheet Requirements includes:
• Diagnosis (ICD 9 and/or ICD 10 codes) included on encounter sheet
• Level of Service (1 through 5)
• Your Signature
Level 2
CC + HPI (1-3), EXAM 1 organ system
Level 3
CC + HPI (1-3) + ROS (1), EXAM 2-7 ORGAN SYSTEMS
LEVEL 4
CC + HPI (4) + ROS (2-9) + PFSH (1), EXAM 2-7 ORGAN SYSTEMS + EXTENDED EXAM OF AFFECTED AREA
LEVEL 5
CC + HPI (4) + ROS (10) + PFSH (2), EXAM >8 ORGAN SYSTEMS
Where is for nurse practice found?
In state legislative statutes and in rules and regulates.
Who authorizes the Board of Nursing to establish statutory authority in each state?
The Nurse Practice Act
What act gives states the mechanisms to mutually recognize APRN licenses/authority to practice across states?
The APRN Compact
What is the purpose of licensure?
To protect the public by ensuring minimal level of professional competence.
_______________ is a process by which an agency of state government grants permission to engage in the practice of that profession and prohibit all others from doing so?
Licensure
_____________ is a process by which a non-governmental agency or association certifies that an individual licensed to practice as a professional has met certain predetermined standards specified by that profession.
Certification
What is the purpose of certification versus licensure?
The purpose of certification is to assure the public that an individual has mastery of a body of knowledge and has acquired skills necessary to function in a particular specialty.
True or false: Some certifications are required for entry into practice, like a licensure within a state.
True
What defines a specific legal scope determined by state statutes, boards of nursing, educational preparation, and common practice within a community.
Scope of Practice
What are authoritative statement by which the quality of practice, service, or education can be judged?
Standard of practice
What provides customers with a means of measuring the quality of care they receive?
Standards of practice
Under what three conditions do the provisions of advanced directives go into effect?
1) The patient has become incompetence
2) The patience is declared terminally ill
3) No further intervention will alter the patient's course to a reasonable degree of medical certainity
The ethical behaviors of nurses have been defined for professional nursing in which document?
American Nurses Association Policy Statement
What is a system designed to evaluate and monitor the quality of patient care and facility management?
Quality Assurance
How may quality insurance be implemented?
Through audits, utilization review, peer review, outcome studies and measurement of patient satisfaction
Who funded the Quality and Safety Education for Nurses?
Robert Wood Johnson Foundation
What four elements must be proved in a case of malpractice?
1) Duty of Care
2) Breach of Care
3) Proximate Cause
3) Damages
Which type of malpractice insurance only covers a claim if both and incident and the claim take place while the policy is in force?
Claims-based policy.
What type of malpractice insurance covers any claim that results from an incident that occurs during the term of the policy, regardless of how long it takes before the claim is made.
Tail coverage
What act was established in 1986 that created a databank to scrutinize members of the healthcare profession and list those practitioners who have had malpractice claims asserted against them?
The Healthcare Quality Improvement Act
True or false: Medicare A does not require a premium.
True
True or false: Medicare B requires a premium.
True
Which type of medicare covers physical and occupational health services?
Part B
What kind of billing takes place when Medicare pays 100% of the physician charge to the NP who provides care to patients under specific guidelines?
Incident to billing
True or false: Under incident to billing, services must be billed under the physician's provider number.
True
True or false: For incident to billing to be reimbursed, the physician must provide the initial visit?
True
Which types of organizations have frequently excluded NPS from being designated primary care providers carrying their own caseloads?
Managed Care Organizations
___________is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed healthcare plans.
The Health Plan Employer Data and Information Set
What defines APRN practice, describes APRN regulatory model, identifies titles to be used, defines specialities, describes emergency of new roles and population foci, and prevents strategies for implementation?
Consensus Model for APRN Regulation
What type of rates describe a group at a certain point in time and the number within a group that a has a particular health problem, like a snap shop in time?
Prevalence rate
Beneficience
the duty to help others
Nonmaleficience
avoidance of harmful behavior
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