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ANCC - Fitzgerald Notecards > Professional Roles and Reimbursement > Flashcards

Professional Roles and Reimbursement Flashcards

1
Q

The Nurse Practitioner Role: History

A

Loretta C. Ford, PhD, RN, FAAN and Henry K. Silver, MD started the 1st NP program at the University of Colorado in 1965
- Initially, it was a certificate program and later became a master’s program in the 1970s
- The first NPs were pediatric NPs who practiced in poor rural areas where there were no physicians (because of a severe shortage of primary care physicians)

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2
Q

Regulation of Nurse Practitioners (NPs): Educational Requirements

A

An NP must meet the minimal educational requirements that are mandated by the nurse practice act of the state (where they plan to practice)

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3
Q

Regulation of NPs: State Nurse Practice Act

A
  • enacted into law by the state legislature
  • Therefore, NPs legal right to practice is derived from the state legislature
  • each state has its own nurse practice act
  • contains regulations that dictate the educational requirements, responsibilities, and scope of practice for NPs and other nurses (e.g., RNs, LPN, midwives) who practice in the state
  • NP practice is NOT regulated by the federal government, the AMA, or the DHHS
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4
Q

Regulation of NPs: State Board of Nursing

A
  • responsible for enforcing the state’s nurse practice act
  • the SBON is a formal governmental agency that has the statutory authority to regular nursing practice
  • they have the legal authority to license, monitor, and discipline nurses
  • also authorized toe revoke a nurse’s license (after formal hearings)
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5
Q

Regulation of NPs: Title Protection

A
  • Professional designations, such as RN, NP, or APRN, are protected by the law
  • it is illegal for any persons to use these titles w/out a valid license
  • total protection is under mandate by a state’s nurse practice act
  • Title protection protects the public from unlicensed “nurses”
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6
Q

Regulation of NPs: Licensure and Certification (Definitions)

A

Licensure: a legal requirement to practice as an NP; obtained through a governmental entities, the SBON
- NP must meet the minimal educational and clinical requirements in order to become licensed

Certification: generally a “voluntary” process and is done through a nongovernmental entity such as a professional nursing association or specialty organization
- majority of states in the US now mandate board certification (or certification) as a condition to obtain licensure

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7
Q

Regulation of NPs: Standards of Professional Nursing Practice
- What are standards?

A
  • Standards are authoritative statements of the duties that all RNs, regardless of role, population, or specialty are expected to perform
  • Per ANA, these include both the Standards of Practice and the Standards of Professional Performance
  • developed by professional societies (e.g., ANA) as well as specialty organizations (e.g., AANP publishes Standards for Practice for NPs)
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8
Q

Regulations of NPs: Collaborative Practice Agreements

A
  • a written agreement b/w a physician and NP outlying the NP’s role and responsibility to the clinical practice
  • copy of the collaborative practice agreement must be kept in the NP’s practice setting and mailed to the SBON
  • most state require an annual review of the agreement, containing signatures of the individuals involved and dates
  • The state practice environment differs for each specific state
  • some states allow full practice under the exclusive authority of the SBON
  • some states allow reduced practice
  • some have restricted practice; in these states, the NP must be under the supervision or delegation of an outside health discipline such as the Board of Medicine
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9
Q

Regulations of NPs: Agreements with Physicians and Dentists

A
  • NPs can sign collaborative practice agreements w/ MDs, DOs, and DMDs/DDSs
  • Chiropractors (DCs) and naturopaths (NDs) are not considered physicians under nurse practice acts
  • Most states, physicians are the only practitioners who can legally sign a death certificate
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10
Q

Regulations of NPs: Prescription Privileges

A
  • majority of states requires NPs to have a written practice protocol w/ a supervising physician in order to prescribe drugs
  • protocol usually contains the list of drugs (by name, class, or condition) that an NP is allowed to prescribe
  • in US, all 50 states grant prescriptive authority to NPs, including the right to prescribe controlled substances (varies by state)
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11
Q

Regulations of NPs: Prescription Pads

A

NP’s prescription pad should contain the following:
- NPI’s name, designation, and license #
- Clinic’s name, address, and phone #;l if the practice has several clinics, the other clinics where the NP practices should also be listed on the pad
- To reduce fraud, it is best if the DEA is NOT listed (only for controlled substance prescriptions)

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12
Q

Regulations of NPs: Food and Drug Administration-Controlled Substances

A
  • Tamper-resistant prescription pads are required by Medicare and Medicaid, as well as when prescribing FDA-controlled substances
  • a controlled substance prescription can be typed, but it must be signed by the prescribing practitioner the day it is issued
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13
Q

Regulations of NPs: Scheduled II Drug Prescriptions

A
  • Substances in this schedule have a high potential for abuse w/ severe psychological/physical dependence
  • CANNOT be called in; MUST be written on tamper-resistant pads and signed by prescriber (not stamped)
  • there is some variation among the different state laws regarding prescriptions of Schedule II drugs

Ex:
- Codeine
- morphine
- hydrocodone
- oxycodone
- opium
- fentanyl
- methadone
- amphetamines

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14
Q

Regulations of NPs: E-Prescribing (Electronic Prescriptions)

A
  • a method of sending prescriptions electronically directly to the pharmacy
  • preferred method of prescribing by Medicare and Medicaid
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15
Q

The Four Generations of Nurses

A

There are not 3 generations that work side-by-side

The “silent generation” group has retired
- each generation behaves differently

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16
Q

The Four Generations of Nurses: “Silent Generation” + Description

A
  • Born from 1925-1945
  • disciplined and loyal
  • traditional work ethic
  • more action oriented
  • the youngest nurses from this generation are now in their 70s, and most have retired
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17
Q

The Four Generations of Nurses: Baby Boomers + Description

A
  • born from 1946-1964
  • hard workers
  • like to achieve
  • more susceptible to burnout and stress-related illness
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18
Q

The Four Generations of Nurses: Generation X (Gen Xers) + Description

A
  • Born from 1965-1980
  • Questions authority
  • expect immediate results
  • loyal to peers over the company
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19
Q

The Four Generations of Nurses: Generation Y (Millennials) + Descriptions

A
  • Born from 1981-2000
  • multitaskers who seek learning and career development
  • also value free time to socialize
20
Q

Nursing Leadership Styles: Situational Leadership

A
  • leader is flexible and can adjust their leadership style to fit the changing needs of an organization
  • can establish rapport easily and bring out the best in people
  • result is that staff members are engaged w/ goals of organization and are more productive
  • this theory was developed by Ken Blanchard and Paul Hersey
21
Q

Nursing Leadership Styles: Transformational Leadership

A
  • leader has ability to communicate vision to staff members
  • may have charismatic personality
  • good communication skills
  • staff members have higher job satisfaction w/ this type of leader
22
Q

Nursing Leadership Styles: Laissez-Faire Leadership

A
  • engages in minimal supervision and direction of stall members
  • Prefers “hands-off” approach
  • may not like to make decisions
  • this style works well if workers are experienced, like autonomy, and are self-directed
  • new or inexperienced staff may feel anxious w/ this type of authority d/t minimal supervision and feedback
23
Q

Nursing Leadership Styles: Authoritarian Leadership (Autocratic)

A
  • Leader likes control and structure
  • prefers to give direction
  • may have many rules
  • makes decisions w/out or minimal staff input
  • motivated, independent, and self-direct staff may be unhappy in this type of environment
24
Q

Nursing Leadership Styles: Democratic Leadership

A
  • leader may like to have more frequent staff meetings because they value staff members’ input and feedback
  • team shares in decision-making process, which may be slow d/t desire to include all of staff in process
  • leader values relationship[s and staff opinions
25
Q

Nursing Leadership Styles: Servant Leadership

A
  • leader likes to work along w/ staff on the unity
  • may assume many roles
  • developers relationships w/ staff members and treats staff as individuals, which results in high job satisfaction for staff
  • this type of leader may not like to make decisions that can “anger” staff members
26
Q

Malpractice Insurance

A

Two types:
- Claims based
- Occurrence based

27
Q

Malpractice Insurance: Claims-based Policy + Tail Coverage

A
  • covers claims only if the incident occurred when the NP paid the premium AND only if the NP is still enrolled w/ the same insurance company at the time the claim is filed in court
  • the claim will NOT be covered (in the future) if they do not have the same insurance company as when the lawsuit was filed
  • buying “tail coverage” can help address this issue

Tail coverage: will cover the NP for malpractice claims that may be filed against them in the future
- when NP w/ claims-based malpractice insurance retires or changes jobs, it is advisable to buy tail coverage insurance

Ex:
- A NP who has been retired for 2 years has a claim filed against her for an incident that occurred while she was employed and insured. The NP discontinued her claims-based malpractice insurance when she retired. In this case, the claim will not be covered, but if she bought tail coverage, then it would be covered

28
Q

Malpractice Insurance: Occurrence-Based Policy

A
  • This policy is not affected by jobs changes or retirement
  • if a claim is filed again the NP in the future, it is covered if they had an occurrence-based policy at the time the incident occurred

Ex:
- An NP who has been retired for 2 years has a claim filed against her for an incident that occurred while she was employed and insured. Since she carried an occurrence-based policy, the claim will be covered

29
Q

Malpractice Lawsuits: Plaintiff

A

The patient or whoever is acting on behalf of the pt (e.g., the pt’s representative) who files the lawsuit claiming injury and/or damage by another party

30
Q

Malpractice Lawsuits: Defendant

A

The part who response to the lawsuit filed by another party who claims an injury and/or damage (e.g., NP, hospital)

31
Q

Malpractice Lawsuits: Elements of a Case

A

The plaintiff must prove that all of the following occurred:
- a duty is owed (a legal duty exists)
- the duty was breached (e.g., not following standard of care)
- the breach caused an injury (proximate cause)
- damaged occurred

32
Q

Malpractice Lawsuits: Phases of a Medical Malpractice Trial

A
  • A lawsuit is filed in the appropriate courts
  • the “discovery” phase (e.g., requesting of medical records, depositions, expert opinions) occurs
  • Plaintiff has the “burden of proof”
  • Court trial phase (or settle out of court or arbitration) occurs
  • The judgement is given
  • Either the case is dismissed or damages are awarded (e.g., physical harm, emotional/mental harm)
33
Q

Malpractice Lawsuits: Expert Witnesses

A
  • Ideally, NP who will testify as an expert witness should be comsone who practices in the same sp[ecialty and geographic area as the NP defendant

Ex: and NP who practices in LA, CA, may not be the best c notice as an expert witness for an NP who is being sued and who is practicing in Miami, FL

34
Q

Reimbursement: Budget Reconciliation Act of 1989 (HR 3299)

A

The first law allowing NPs to be reimbursed directly by Medicare
- Prior to this act, only certified pediatric and family NPs were allowed to be primary providers as long as they practice in designated “rural” areas

35
Q

Reimbursement: Balance Budget Act of 1997

A

-Together w/ Primary Care Health Practitioner Incentive Act…
- This law broadened Medicare coverage of NP and CNS services

  • HIPAA of 1996 required health providers to have an NPI # to bill Medicare and Medicaid
  • NPs can be reimbursed directly be Medicare Part B, Medicaid, Tricare, and some health insurance plans
  • Medicare will reimburse NPs at 85% by the Medicare Physician Fee Schedule
36
Q

Reimbursement: National Provider Identifier Number

A

A unique 10-digit ID # assigned to healthcare providers (or to any entity that bills Medicare/Medicaid)
- issued by the National Plan and Provider Enumeration System (NPPES)
- All providers who provide services and bill Medicare MUST have an NPI #
- Individual healthcare providers may obtain only one NPI for themselves

  • To become a Medicare-approved provider, one must first obtain an NPI # online
  • an individual provider’s NPI identified lasts for their lifetime
  • the identifier does NOT change regardless of state or group affiliations
  • Medicare requires the NPI # for financial transactions
  • Electronic claims submission is required by Medicare and Medicaid
  • Medicare uses electronic fund transfer (EFT) to reimburse providers
37
Q

Reimbursement: “Incident-to” Billing and Medicare

A
  • a way to bill Medicare for outpt services rendered by a non physician health provider (NP, PA) and receive the 100% physician fee
  • location of the services can be at the physician’s office, a separate or satellite office, or an institution or in the pt’s home
  • During the first visit, the physician MUST evaluative the pt (and write a care plan)
  • Follow-up visits by the NP can be billed as “incident to” so long as the same health problems are being addressed
  • The physician’s NPI # is used to bill for the service
  • the “incident-to” billing is reimbursed at 100% of the physician rate
  • BUT if the same pt is seen for a new prolly by the NP/PA, then the visit is billed under the NP/PA NPI # (85% of the physician fee)
38
Q

Reimbursement: Medical Coding and Billing

A

Every time an NP bills Medicare, Medicaid, and/or a health insurance plan, they must submit an electronic claim
- The claim form, or the “super bill” must contain BOTH the ICD, 10th edition, codes OR the diagnosis and the Current Procedural Terminology (CPT) codes

If the bill is missing the ICD-10 code or CPT code, the bill will be rejected (not paid) and it has to be resubmitted with the required information
- The services rendered must show medical necessity and the appropriateness of diagnostic and/or therapeutic services that were completed

39
Q

Medical Coding and Billing: What is the ICD-10 Code?

A
  • used to indicate the pt’s diagnosis as deterred by the International Classification of Diseases, 10th edition (WHO, 2016)
  • Each disease is assigned a specific ICD-10 code
40
Q

Medical Coding and Billing: What is an ICD-10 “Z-Code” (Z00-Z99)?

A
  • uses Z-codes to indicate the reason for each pt’s encounter
  • If a procedure is preformed, a corresponding CPT code must accompany each Z-code

Ex:
- to justify the procedure, vaccinations, screening, counseling, others

41
Q

Medical Coding and Billing: What is the CPT?

A
  • a5-digit code or alphanumeric code (letter w/ the digits) that is used to identify medical procedures (suturing, I&D, and other medical services)
  • owned and maintained by the AMA
42
Q

Medical Coding and Billing: What are E&M Codes?

A
  • Evaluation and Management Service (E&M codes are used to bill for pt visits and are part of the CPT
  • if a bill is missing an E&M code, the healthcare provider will NOT be reimbursed for the time they spent w/ the pt
  • E&M codes are based on the history, examination, and medical decision-making (complexity) that take place
  • provider MUST document that theses 3 components have been met (or exceeded)
  • The complexity and time spent w/ the pts are assigned codes by the CPT system

Ex: A “problem-focused” visit requires documentation of the chief complaint w/ a brief hex of present illness (HPI), but it does not require a review of systems (ROS) or a past, family, and/or social hx

43
Q

Health Technology: Telehealth

A
  • a broad term that encompassed a range of services and technologies designed to extend access, capacity, and delivery of healthcare, as well as improve pt care and outcomes

Services include:
- videoconferencing (e.g., consultation b/w pt and provider)
- pt monitoring (e.g., devices that remotely collect and send pt data to providers or testing facilities)
- mobile health (e.g., pt health portals or personal health apps)

Telehealth is not restricted to clinical services
- can also include a wide range of non clinical services such as provider training and continuing education

44
Q

Health Technology: Telemedicine

A
  • a subset of Telehealth
  • refers to remote clinical services provided via secure audio and video connection
  • commonly used for management of chronic conditions, mediation management, follow-up visits, and specialist consultation
45
Q

Health Information technology for Economic and Clinical Health Act (HITECH Act)

A
  • signed into law in 2009 as an incentive for healthcare providers to adopt the use of electronic health records (EHRs) and supporting technology
  • included incentives for early adoption of those technologies until 2015
  • After 2015, it began to issue financial penalties (e.g., reductions of Medicare and Medicaid reimbursement) for providers and entities who had NOT adopted EHR technologies
  • it also strengthened enforcement of HIPAA security and privacy laws and penalties for breaches
46
Q

Which entity enables NPs their “right to practice?

A

The State legislature

ANCC - Fitzgerald Notecards (27 decks)

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