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Professional Nursing Unit 3 Exam: The Wonderful World of Reimbursement

Terms in this set (77)

The nurse is asked by a patient, "why is it necessary to have deductibles and copayments when I already have health insurance?" The best response would be:
"They are a way to improve the margin of profit in the fee-for-service method of paying for health care."
A patient tells the nurse, "I didn't sign up for health care insurance at my job because I'm young and healthy and can use the money in other ways." The response that best explains the advantage of health insurance would be, "with insurance...":
"You are spreading the risk in case you have a serious health event, such as cancer or major trauma."
A patient asks the nurse, "what do health maintenance organizations (HMOs) do to reduce health care costs?" The response giving the best example of an HMO cost-containment method would be:
"HMOs provide services aimed at keeping members healthy."
When involved with discharge planning for a patient recovering from a mild cerebrovascular accident, the nurse should understand that Medicare provides:
Increased use of extended care units for rehabilitation needs.
Diagnosis-related groups (DRGs) and prospective payment systems are most clearly the reason for:
Critical pathways and managed care.
A patient tells the nurse, "I received a questionnaire that said my answers would be used for purposes of continuous quality improvement. I wonder if it's worth my time to fill it out?" The response that best explains continuous quality improvement is, "continuous quality improvement activities are used to...":
"Monitor and improve processes involved in providing safe, effective care for patients."
A 70-year-old patient tells the nurse, "I can't go to the hospital for treatment, because I have no hospital insurance. My Social Security and my pension pay my living expenses, but I don't have any savings." The nurse's response should be focused on:
Providing information about Medicare.
A mother and her three children often seek medical services at the emergency room. The nurse realizes that they have no insurance and are unable to pay for services. The action the nurse should take that would provide the greatest assistance to the family would be to:
Contact a social worker to discuss Medicaid with the mother.
Which program offers an incentive to hospitals to discharge patients as quickly as possible?
Prospective payment system.
A trend in health care that may negatively affect the number of practical nurses hired by an agency is:
The increased use of unlicensed assistive personnel.
Which of the following is a quality improvement activity in which the LPN/LVN engages routinely?
Collecting data for care plan development.
Which LPN/LVN will be most successful in dealing with change?
Nurse U, who sees change as an opportunity to improve conditions.
The skill that will be most helpful to an LPN/LVN in navigating health care system changes successfully is:
Problem-solving and critical thinking abilities.
A set monthly fee charged by the provider of health care services for each member of the insurance group for a specific set of services is known as:
Capitation.
A method of financing health care costs in which physicians are paid a fee by the patient for each service they provide is known as:
Fee-for-service.
The monthly fee a person must pay for health care insurance coverage is known as the:
Premium.
The yearly amount an insured person must spend out-of-pocket for health care services before a health insurance policy will begin to pay its share is known as the:
Deductible.
The amount an insured person must pay at the time of an office visit, when picking up a prescription, or before a hospital service is known as the:
Copayment.
Once a deductible has been met, the percentage of the total bill paid by the insured person is known as the:
Coinsurance.
A student nurse asked to identify the types of services currently provided in the U.S. health care delivery system should mention which of the following? (Select all that apply.)
Health promotion.

Diagnosis and treatment.

Illness prevention.
Which of the following phrases could be used by a nurse to characterize the present health care delivery system in the United States? (Select all that apply.)
Responds to illness.

Is fragmented and confusing.

Is unsafe.
Which of the following are problems associated with the present health care delivery system that could be identified by a nursing student who is writing an essay? (Select all that apply.)
High cost.

Widespread shortage of RNs.
The LPN/LVN charge nurse has been designated to participate in the orientation of a new LPN/LVN by explaining cost-containment measures. Measures the charge nurse should mention include which of the following? (Select all that apply.)
Charge patients for all supplies used in their care.

Document patient care according to the policy for reimbursement.

Use time management principles to work efficiently.

Use supplies carefully to avoid waste.

Implement measures to prevent complications.
An example of a public sector health care agency supported primarily by U.S. taxpayer dollars is the:
U.S. Public Health Service.
A nurse is asked, "What does it mean if a health care agency is described as 'proprietary'?" The nurse should respond:
"It operates for profit."
An example of a voluntary health agency that is focused on research and education of the public is:
The American Heart Association.
Knowing that Alcoholics Anonymous is a nonprofit group that receives no taxpayer money and is aimed at meeting the needs of a selected population segment would help the nurse to classify it as a:
Voluntary agency.
A nurse working in the emergency department who must obtain data to identify the patient's primary care provider should ask the patient about:
The referring physician, nurse practitioner, or ambulatory care setting.
A patient tells the nurse, "I was treated for an asthma attack at a freestanding ambulatory services center." The nurse correctly identifies the treatment as taking place at a/an:
Urgent care center.
An elderly patient is to be discharged from the acute care hospital with left-sided weakness, difficulty swallowing, and inability to independently perform ADLs, therefore requiring daily physical therapy. The patient has no family and lives in a high-rise apartment building. Referral to which level of long-term care would the nurse likely recommend at the care planning conference?
Skilled nursing facility.
A patient who had a cerebrovascular accident needs nursing care, physical therapy, and speech therapy. The patient's spouse would like to provide care at home but needs assistance. During the planning conference, the nurse should suggest that the agency that could best meet the patient's needs is:
A home health agency.
After several weeks of outpatient care, a patient with a badly burned hand has been referred for rehabilitation. The patient asks the nurse what the purpose of rehabilitation is. The best answer would be:
"It will help you get back the function of your hand and will prevent further disability."
Which individual is best served by receiving care at an adult day care center?
Mr. D, who has first-stage Alzheimer's disease and a working wife.
At a patient care planning conference, the nurse hears the remark, "We need to report this event to our official public health agency." The nurse interprets this as meaning the speaker will contact the:
Local health department.
The United States Public Health Service (USPHS) is funded by:
Tax money.
Accountability of private health care agencies is assumed by the:
Owners of the agency.
___________________ are for-profit hospitals operated for the financial benefit of the owner of the hospital.
Proprietary hospitals.
The health care agency that provides information and support for breast-feeding mothers and breast milk for infants because of health reasons is the______________.
LaLeche League.
Which of the following are types of health care agencies in which the LPN/LVN would most likely find work? (Select all that apply.)
Skilled nursing facility.

Hospice.
An advantage of preferred provider organizations (PPOs) is that:
Patients may go directly to a specialist for care.
When diagnosis-related groups (DRGs) were established by Medicare in 1983, the purpose was to:
Attempt to contain the costs of health care.
Which of the following is considered a positive aspect of the Affordable Care Act?
Maria, age 60, is able to obtain health insurance at a rate that is manageable on her income.
Which action by the nurse helps to achieve the goals of the Hospital Readmissions Reduction Program?
The nurse ensures that the patient understands how to take prescribed medications correctly.
Which is an example of capitation in health care?
The patient's primary care physician is paid a flat monthly fee no matter how many appointments are scheduled with the patient.
Which is an example of health care disparity?
The physician treats cardiac patients with insurance more aggressively than noninsured patients.
Which assessment question allows an administrator to determine the level of patient satisfaction after hospitalization?
"Did the nursing staff treat you with respect and maintain your privacy?"
Which is an example of a Bundled Payment for Care Improvement?
The hospital is paid a predetermined lump sum for all costs related to the patient's open heart surgery.
The advent of diagnosis-related groups (DRGs) required that nurses working in health care agencies:
Record supportive documentation to confirm a patient's need for care in order to qualify for reimbursement.
Such health services as surgical procedures, restorative care, and home health care would be classified as __________ care.
Secondary.
Which nursing care delivery system has been fully embraced by the nursing community and is identified as one of the seven QSEN competencies?
Patient-centered care.
Which feature of the hospital enables it to qualify for Magnet Recognition Program?
The nurses utilize evidence-based practice and flexible staffing plans.
The patient uses a special telephone connection to allow the cardiologist to assess the patient's pacemaker function while the patient stays at home. Which term is used to describe this type of health care?
Telemedicine.
A nurse is asked about public health care agencies. Which of the following would help the nurse frame a comprehensive response? (Select all that apply.)
There are two types of public health agencies: official and voluntary.

Public health agencies emphasize disease prevention, wellness promotion, research, and education.
"Value-based purchasing" is a payment method that offers financial incentives to MDs and hospitals for meeting quality:
Pay for performance (P4P).
The P4P, or pay for performance model, penalizes healthcare providers for:
Poor surgical outcomes.

Facility acquired infections.

Medical or medication errors.
What relative value assigned to a group of patients is used for allocation of resources to treat specific diseases?
Case Mix Index (CMI).
The system used by physicians and healthcare providers to classify and code all diagnoses, symptoms, and procedures recorded is:
International Classification of Diseases (ICD).
ICD is maintained by WHO, which is designed to map health conditions and classify disease for morbidity and mortality. What data should be collected?
Variety of signs and symptoms and abnormal findings.

External causes of injury or disease.

Social circumstances.
What are categories that reflect the levels of resource needs in long-term-care settings, primarily to facilitate Medicare/Medicaid payment?
Resource utilization groups (RUGs).
What is the classification system that standardizes prospective payment to hospitals and encourages cost containment?
Diagnosis related groups (DRGs).
What is the federally mandated process that entails comprehensive, standardized assessment of functional and health needs for long-term-care?
Minimum data set (MDS).
What is the classification system for outpatient services reimbursement?
Ambulatory patient group (APG).
Under the DRG system, the hospital:
Receives a set amount of money for each patient hospitalized with a particular diagnosis.
Which federal health care agency advises the president of the United States in health matters?
Department of Health and Human Services.
Which act created reform in the health care system?
Affordable Care Act.
Group health insurance works by:
Pooling individual contributions to protect from financial disaster due to billing.
Medicare Part A pays for:
Inpatient hospital stay.
Medicaid is:
An entitlement program jointly funded by state and federal government.
The prospective payment system is:
When the federal government announces to hospitals in advance what costs will be paid.
The rapid development of a variety of ambulatory services is directly related to:
The rising cost of inpatient care.
Medicare Part B helps pay for:
Diagnostic tests.
An alternative to the fee-for-service method of payment is:
Capitation.
Two major ways to finance health care services are:
Fee-for-service and capitation.
The Affordable Care Act established a:
Health insurance marketplace.
Proprietary hospitals are primarily supported by:
Private owners or corporations.
An example of a private health agency is:
Primary care physician.
An advantage to the patient of a managed health care system is:
Paying lower health insurance costs and smaller co-payments.
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