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Incident to Billing in Healthcare
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Incident to Billing in Healthcare

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Questions and Answers

What is one disadvantage of incident to billing for nurse practitioners (NPs)?

  • It guarantees reimbursement for all services rendered.
  • It offers NPs the same reimbursement rates as physicians.
  • It suggests a hierarchical approach to care. (correct)
  • It allows NPs to bill under their own NPI numbers.

    • How does incident to billing affect the visibility of NP care on a national level?

  • It makes NP care invisible by billing under physicians' NPI numbers. (correct)
  • It leads to increased media coverage of NP roles.
  • It allows for better tracking of NP services through unique identifiers.
  • NP care becomes more recognizable due to improved NPI usage.

    • Which organization suggested eliminating incident to billing to improve NP practice authority?

  • Medicare Payment Advisory Commission (MedPAC) (correct)
  • American Association of Nurse Practitioners (AANP)
  • American Nurses Association (ANA)
  • Centers for Medicare and Medicaid Services (CMS)

    • What is the primary reason third-party payers dictate reimbursement policies for NPs?

    <p>They are generally organized into specific categories.</p> Signup and view all the answers

    Which of the following statements about primary payers is NOT accurate?

    <p>Auto liability covers only those insured through their employer.</p> Signup and view all the answers

    Which action did the Centers for Medicare and Medicaid Services (CMS) undertake in 1997?

    <p>Enacted the Balanced Budget Act to address healthcare costs.</p> Signup and view all the answers

    What are

    <p>Individuals without health insurance.</p> Signup and view all the answers

    What can be a positive outcome of eliminating incident to billing for NPs?

    <p>Enhanced recognition of NPs as independent providers.</p> Signup and view all the answers

    What is the Medicare Part A deductible for hospital services in 2021?

    <p>$1,484</p> Signup and view all the answers

    What is the coinsurance rate for hospital stays from days 61 to 90 under Medicare Part A in 2021?

    <p>$371 per day</p> Signup and view all the answers

    How much does a patient pay as a copayment per day for skilled nursing facility services from days 21 to 100 under Medicare?

    <p>$185.50 per day</p> Signup and view all the answers

    What percentage of the physician's fee is reimbursed to nurse practitioners under Medicare?

    <p>85</p> Signup and view all the answers

    What was the deductible amount for Medicare Part B in 2021?

    <p>$203</p> Signup and view all the answers

    Which agency is responsible for identifying which services will be reimbursed under the Medicare Physician Fee Schedule?

    <p>5010</p> Signup and view all the answers

    What is the maximum coinsurance fee a beneficiary could face after exhausting their lifetime reserve days under Medicare?

    <p>All costs</p> Signup and view all the answers

    What is the typical range of monthly premium costs for secondary insurance plans that cover the 20% out-of-pocket expense for traditional Medicare patients?

    <p>$50 to $300</p> Signup and view all the answers

    What is one of the primary attractions of Medicare Advantage plans for users?

    <p>Ease of using one plan for covered benefits</p> Signup and view all the answers

    What type of plans are classified under Medicare Advantage?

    <p>Preferred Provider Organization (PPO) plans</p> Signup and view all the answers

    Why have many Medicare Advantage plans found the market less financially viable?

    <p>High medical utilization and greater healthcare costs of beneficiaries</p> Signup and view all the answers

    What defines the annual payment structure for Medicare Advantage plans?

    <p>Subsidies per member paid by CMS for services rendered</p> Signup and view all the answers

    Which of the following best describes the impact of Medicaid expansion on states that accepted it?

    <p>It resulted in a positive financial budget and economic impact.</p> Signup and view all the answers

    How does Medicaid differ from Medicare in terms of funding?

    <p>Jointly funded by federal and state governments</p> Signup and view all the answers

    What is one of the primary roles of third-party payers in healthcare?

    <p>They determine reimbursement policies for healthcare providers.</p> Signup and view all the answers

    Who is exempt from meeting the Modified Adjusted Gross Income (MAGI) requirements for Medicaid eligibility?

    <p>Citizens who are blind or elderly</p> Signup and view all the answers

    What is a common problem faced by Medicare Advantage plans regarding their beneficiaries?

    <p>Unexpected higher costs for noncovered services</p> Signup and view all the answers

    Which of the following categories is NOT considered a type of third-party payer?

    <p>Cash payments by patients</p> Signup and view all the answers

    Which of the following is NOT a type of Medicare Advantage plan?

    <p>Supplemental Insurance plans</p> Signup and view all the answers

    How do third-party payers generally use Medicare and Medicaid guidelines?

    <p>As a foundation for their own fee schedules.</p> Signup and view all the answers

    What is the role of the National Provider Identifier (NPI) in the billing process?

    <p>It identifies providers in HIPAA transactions.</p> Signup and view all the answers

    What action must healthcare providers take to bill Medicare?

    <p>They are required to apply for enrollment in Medicare.</p> Signup and view all the answers

    What percentage of the fee schedule rate do payments based on CMS billing rules typically represent for nonphysician practitioners?

    <p>85%</p> Signup and view all the answers

    What is the purpose of the Balanced Budget Act of 1997 regarding billing?

    <p>To facilitate billing for nonphysician practitioners.</p> Signup and view all the answers

    Which pattern of knowing is primarily guided by intuition and personal experience?

    <p>Personal knowing</p> Signup and view all the answers

    What is a potential conflict that may arise regarding commitment in nursing?

    <p>Patient calls conflicting with economically driven care</p> Signup and view all the answers

    In the OLD CART format, what does 'A' stand for?

    <p>Aggravating factors</p> Signup and view all the answers

    What does a healthcare proxy enable a person to do?

    <p>Communicate treatment decisions on behalf of a patient</p> Signup and view all the answers

    Which ethical principle emphasizes the importance of truth-telling in nursing?

    <p>Veracity</p> Signup and view all the answers

    What is the primary focus of the ethical principle of beneficence?

    <p>Promoting positive actions and benefits</p> Signup and view all the answers

    Deontology is an ethical theory focused on what aspect?

    <p>Following rules and duties</p> Signup and view all the answers

    Which element of the diagnostic process helps refine hypotheses through patient history?

    <p>Medical history</p> Signup and view all the answers

    Which of the following describes 'teleological ethics'?

    <p>Ethics that evaluate the outcomes of actions</p> Signup and view all the answers

    What document outlines a person's medical treatment preferences when unable to make decisions?

    <p>Living will</p> Signup and view all the answers

    Which of the following is NOT an ethical principle in nursing?

    <p>Paternalism</p> Signup and view all the answers

    What aspect of patient care does 'nonmaleficence' primarily emphasize?

    <p>Avoiding causing harm</p> Signup and view all the answers

    Which provision of the ANA's code of ethics focuses on maintaining nursing competence?

    <p>The nurse owes the same duties to self as to others</p> Signup and view all the answers

    What is the function of diagnostic tests in nursing?

    <p>To confirm or screen for conditions</p> Signup and view all the answers

    Study Notes

    Incident to Billing

    • Allows supervising physicians to be reimbursed for 100% of the billed amount, compared to 85% for independent NPs.
    • Reinforces the hierarchy in healthcare by implying NP care is inferior and requires physician oversight.
    • NPs' contributions become invisible as all services are billed under physicians' NPI numbers, hindering Medicare's ability to recognize NP services.

    Third-Party Payer Categories

    • Seven general categories: Medicare (A, B, C, D), Medicaid, indemnity insurance, managed care organizations (MCOs), workers' compensation, Veterans Administration, and auto liability.
    • Includes those without health insurance, termed private pay, who often face significant financial constraints.
    • Each payer has distinct policies, but all adhere to CMS guidelines for health care delivery and reimbursement.

    Medicare and NPs

    • Nonphysician practitioners, including NPs, received billing approval from CMS through the Balanced Budget Act of 1997.
    • NPs typically receive 85% of the physician's fee under Medicare, with patients responsible for a 20% co-payment.
    • Medicare Part A involves hospital services with specific out-of-pocket costs for various lengths of stay, and the deductible was $1,484 in 2021.
    • Medicare Part B covers outpatient services, with a yearly deductible of $203 in 2021.

    Medicaid Overview

    • Jointly funded by federal and state governments to provide assistance to low-income individuals and families.
    • Eligibility includes children, pregnant women, parents, seniors, and individuals with disabilities, determined by Modified Adjusted Gross Income (MAGI).
    • States opting for Medicaid expansion saw significant financial benefits due to increased federal funding.

    Diagnostic Process

    • OLD CART method identifies patient symptoms: onset, location, duration, characteristics, aggravating/relieving factors, and treatment.
    • CSOC outlines essential components for understanding a patient’s chief complaint and establishing rapport.

    Healthcare Power of Attorney and Living Wills

    • A healthcare POA designates someone to make medical decisions when a patient is unable, functioning alongside a living will.
    • A living will outlines specific treatment preferences, organ donation desires, and end-of-life care options.

    Ethics in Healthcare

    • Ethics is defined as determining what ought to be done, especially in bioethical dilemmas.
    • ANA's code of ethics highlights the importance of patient commitment, rights advocacy, professional integrity, and health improvement.
    • Key ethical principles include autonomy, beneficence, nonmaleficence, veracity, confidentiality, fidelity, and justice.

    Malpractice Considerations

    • Essential elements include the duty to the patient, deviation from care standards, and resultant harm.
    • Two insurance policies:
      • Claims-based covers incidents only during active coverage.
      • Occurrence-based covers incidents regardless of current insurance status.

    Reimbursement Challenges for APRNs

    • Unequal pay persists in Medicare and Medicaid practices, with significant implications for NP financial viability and practice authority.
    • Mandated LACE requirements (licensure, accreditation, certification, education) for APRN standards of practice establish pathways for qualification and employment.

    Teleological vs. Deontological Ethics

    • Teleological ethics focus on the consequences of actions, aiming for the greatest good.
    • Deontological ethics, stemming from Immanuel Kant, emphasizes duty and moral rules as guides for ethical behavior.

    Healthcare Payment Models

    • Medicare Advantage (MA) plans provide various coverage options but have faced sustainability challenges.
    • Beneficiaries face higher costs for non-covered and out-of-pocket services, impacting access to care.

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    Description

    This quiz explores the concept of incident to billing, which allows supervising physicians to receive full payment for services rendered by nurse practitioners (NPs). It discusses the implications for NP practice, the perception of care quality, and the hierarchical nature of this billing method. Test your understanding of the advantages and drawbacks of incident to billing in healthcare settings.

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