Professional Roles and Reimbursement Flashcards
Educational requirements are regulated by
the Nurse Practice Act
State Nurse Practice Act
- legal right to practice is derived from this
- Each state has their own NPA
- Not regulated by federal government
State Board of Nursing
-responsible for enforcing the state’s nurse practice act
Who is authorized to revoke a nurse’s license
State BON
Title protection
- professional delegations are protected by law
- illegal to use these names (RN, FNP) without a valid license
Collaborative practice agreements
- written agreement between a physician and NP outlining the NP’s role and responsibility to the clinical practice
- copy must be kept at NP’s practice setting and mailed to state BON
Which “doctors” are not considered physicians under the NPA
chiropractors
naturopaths
Prescription privileges
- majority of states require the NP to have a written protocol with a supervising physician in order to prescribe drugs
- usually contains a list of drugs that an NP is allowed to prescribe
DEA number should be on all prescription pads
No
only when prescribing controlled substance prescriptions
-avoid fraud this way
Situational leadership
- flexible leadership
- adjust to changing needs of an organization
- can establish rapport easily and bring out the best in people
Transformational leadership
- ability to communicate vision to staff members
- charismatic personality
- good communication
- staff usually has higher job satisfaction with this type of leadership
Laissez-Faire leadership
- engages in minimal supervision and direction of staff
- hands off approach
- works well if workers are experienced, autonomous, and self-directed
- new and unexperienced staff may feel anxious
Authoritarian (Autocratic) leaderships
- likes control and structure
- prefers to give directions
- many rules
- directions without staff input
- motivated, independent, and self-direct staff may be unhappy
Democratic leadership
- like more frequent staff meetings, values input and feedback
- shares decision making
Servant leadership
- likes to work along with staff on unit
- may assume many roles
- treats members as individuals
- may not like to make decisions that anger staff
What kind of insurance is malpractice insurance
- claim-based
- occurrence based
Claims-based policy
- covers claims only if incident occurred when NP paid the premium and only if the NP is still enrolled with the same insurance company at the time the claim is filed in court
- buying “tail coverage” can help resolve this
What is tail coverage
- covers the NP for malpractice claims that may be filed against him or her in the future
- recommended when retiring or changing jobs
Occurrence-based policy
- not affected by job changes or retirement
- if claim is filed in the future, it is covered if they had an occurrence-based policy at the time of the incident
Plaintiff
-the patient or whoever is acting on behalf of the patient who files the lawsuit claiming injury and/or damage
Defendant
-the party who responds to the lawsuit filed by another party
elements of a case
- plaintiff must prove that all of the following occurred
- duty is owed
- duty was breached
- proximate cause (breach caused an injury)
- damage occurred
Phases of a malpractice trial
- lawsuit filed
- discovery phase: medical records, deposition, expert opinions
- plaintiff has burden of proof
- court trial phase
- judgment given
- dismissed or damages rewarded
Exerpt witness
-Expert witness should be someone who practices in the same specialty and geographic area as the defendant
Budget Reconciliation act of 1989
first law allowing NPs to be reimbursed directly by Medicare
Balance Budget act of 1997
- Broadened Medicare coverage of NP and CNS services
- can be reimbursed directly by Medicare Part B, Medicaid, Tricare, and some health insurance plans
- Medicare will reimburse NPs at 85% of the Medicare Physician Fee schedule
NPI number
- unique 10 digit number assigned to any HCP that bills to Medicare/Medicaid
- number will never change
“Incident to” billing and Medicare
- way to bill Medicare for outpatient services rendered by a nonphysician health provider (NP, PA) and receive 100% of physician fee.
- first visit must be by a physician and write a care plan
- F/u visits by NP can be billed as “incident to” so long as the same health problems are being addressed
- physician’s NPI number is used to bill for service
- if patient is seen for a new problem by the NP, then it is billed under the NP at 85% fee rate
By what entity is the ICD-10 code determined by
WHO
What is an ICD-10 Z code
-Z-codes indicate the reason for each patient encounter
if a procedure is performed, a CPT code my accompany each Z-code to justify the procedure, test, encounter, etc.
What is CPT
-identify procedures and other medical cervices
What entity maintains CPT
American Medical Association
What are E&M codes (Evaluation and Management)
- used to bill for patient visits
- part of CPT
- will not be reimbursed if this is missing
- based on history, exam, and medical decision making
Reportable diseases
- TB
- diptheria
- hepatitis A, B, C
- measles
- mumps
- pertussis
- Lyme
- RMSF
- etc.
What is a third party payer
health insurance companies
-health plans PPO, HMO
-Medicare
Medicaid
What is the first party
patient
what is the second party
health care provider
