Government Flashcards
Diagnosis related groups
system to classify hospital cases in one of 467 groups based on the services/products they offer
Allows Medicare to determine how much each service/product will be reimbursed based on grouping
Critical pathway contains
a blueprint for planning and managing care delivered by all disciplines
IE: structure after cardiac surgery such as vital signs, labs,, and diagnostic tests
Medicare Part A covers
Inpatient services Skilled Nursing facilities Hospice LTAC Inpatient rehab Home health care obesity-bariatric surgery
Medicare Part B covers
NP can reimburse under this as long as it is “physician like” cares and not “nursing like” cares
outpatient hospital care physician visits home care lab services radiology services
Managed Care Networks
contractually agree to provide services for certain patient groups
“Incident to” billing
NP was a ble to perform services ordinarily performed by physician
Cannot be used with new patients
Must be in a defined office/suite
Cannot be used in inpatient setting
NPs can be reimbursed nationally by
CHAMPUS
Preferred Provider Organizations (PPO)
type of managed care system
partnership between group of preferred physicians and insurance companies to provide specific medical and hospital care at prearranged costs
National Practitioner Data Bank
Compiles information on medical-legal actions taken against healthcare professionals
Includes malpractice settlements and adverse actions that influence clinical privileges/licensure
Hospitals are required to quirky the NPDB
Confidentiality and privacy
privacy breach is using patients name or identifiers without permission
Confidentiality is priority over privacy
Confidentiality protects sharing of information
ACNP practice models
Service based
Practice based
Population based
Service based practice model
clinical management by group
IE: medical/surgical team; surgical oncology/neurology
Practice based practice model
clinical management by setting/unit
Population based practice model
management of specific disease
IE: diabetes
Goals of Healthy People 2020
- long lives of preventable diseases
- Achieve healthy equity, eliminate disparity
- Create social/physical environment to promote health
- promote quality of life, healthy development
Medicaid
federally supported/funded
State based and administered
Medicaid pays last
Patient Self Determination Act of 1990
right to execute advanced directive
Must provide patient rights at admission
Ask if patient has advanced directives
Prohibits institution to require advanced directive
Prescription authority and death certificate is regulated by
state
ANA essential roles of ACNPs
RECCC
researcher educator clinician collaborator consultant
Advanced directives are
are guidelines and not typically legally binding
Must seek attorney
Patient components of Informed consent
Capacity to make decision
Comprehension of information
Can ask questions
Occurrence based insurance
covers injuries that occur during period policy was active regardless if it was renewed
best coverage, most expensive
Claims-made insurance
covers the clinician only if the injury occurs within the policy period and if claim is filled during policy period
Typically want tail cover for this
Tail coverage insurance
policy that covers period of expiration claims made to end of statute of limitations (2 years)
Expensive but safe after leaving job
Malpractice must include
duty to patient (your patient)
violated standard of care
Caused damages
Medicare Part C
offered by private companies
provide PPO or HMO serives
Medicare Part D
Drug prescription coverage
Must have part A and B to have part D
Premium is charged
