Professional Roles and Reimbursement

Question 1

Educational requirements are regulated by

Answer 1

the Nurse Practice Act

Question 2

State Nurse Practice Act

Answer 2

• legal right to practice is derived from this
• Each state has their own NPA
• Not regulated by federal government

Question 3

State Board of Nursing

Answer 3

-responsible for enforcing the state’s nurse practice act

Question 4

Who is authorized to revoke a nurse’s license

Answer 4

State BON

Question 5

Title protection

Answer 5

• professional delegations are protected by law

- illegal to use these names (RN, FNP) without a valid license

Question 6

Collaborative practice agreements

Answer 6

• 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

Question 7

Which “doctors” are not considered physicians under the NPA

Answer 7

chiropractors

naturopaths

Question 8

Prescription privileges

Answer 8

• 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

Question 9

DEA number should be on all prescription pads

Answer 9

No
only when prescribing controlled substance prescriptions
-avoid fraud this way

Question 10

Situational leadership

Answer 10

• flexible leadership
• adjust to changing needs of an organization
• can establish rapport easily and bring out the best in people

Question 11

Transformational leadership

Answer 11

• ability to communicate vision to staff members
• charismatic personality
• good communication
• staff usually has higher job satisfaction with this type of leadership

Question 12

Laissez-Faire leadership

Answer 12

• 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

Question 13

Authoritarian (Autocratic) leaderships

Answer 13

• likes control and structure
• prefers to give directions
• many rules
• directions without staff input
• motivated, independent, and self-direct staff may be unhappy

Question 14

Democratic leadership

Answer 14

• like more frequent staff meetings, values input and feedback
• shares decision making

Question 15

Servant leadership

Answer 15

• 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

Question 16

What kind of insurance is malpractice insurance

Answer 16

• claim-based

- occurrence based

Question 17

Claims-based policy

Answer 17

• 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

Question 18

What is tail coverage

Answer 18

• covers the NP for malpractice claims that may be filed against him or her in the future
• recommended when retiring or changing jobs

Question 19

Occurrence-based policy

Answer 19

• 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

Question 20

Plaintiff

Answer 20

-the patient or whoever is acting on behalf of the patient who files the lawsuit claiming injury and/or damage

Question 21

Defendant

Answer 21

-the party who responds to the lawsuit filed by another party

Question 22

elements of a case

Answer 22

• plaintiff must prove that all of the following occurred
• duty is owed
• duty was breached
• proximate cause (breach caused an injury)
• damage occurred

Question 23

Phases of a malpractice trial

Answer 23

• lawsuit filed
• discovery phase: medical records, deposition, expert opinions
• plaintiff has burden of proof
• court trial phase
• judgment given
• dismissed or damages rewarded

Question 24

Exerpt witness

Answer 24

-Expert witness should be someone who practices in the same specialty and geographic area as the defendant

Question 25

Budget Reconciliation act of 1989

Answer 25

first law allowing NPs to be reimbursed directly by Medicare

Question 26

Balance Budget act of 1997

Answer 26

• 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

Question 27

NPI number

Answer 27

• unique 10 digit number assigned to any HCP that bills to Medicare/Medicaid
• number will never change

Question 28

“Incident to” billing and Medicare

Answer 28

• 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

Question 29

By what entity is the ICD-10 code determined by

Answer 29

WHO

Question 30

What is an ICD-10 Z code

Answer 30

-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.

Question 31

What is CPT

Answer 31

-identify procedures and other medical cervices

Question 32

What entity maintains CPT

Answer 32

American Medical Association

Question 33

What are E&M codes (Evaluation and Management)

Answer 33

• 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

Question 34

Reportable diseases

Answer 34

• TB
• diptheria
• hepatitis A, B, C
• measles
• mumps
• pertussis
• Lyme
• RMSF
• etc.

Question 35

What is a third party payer

Answer 35

health insurance companies
-health plans PPO, HMO
-Medicare
Medicaid

Question 36

What is the first party

Answer 36

patient

Question 37

what is the second party

Answer 37

health care provider