Deck 20: Regulatory and Reimbursement Issues

Question 1

Owens has come to the clinic to see the nurse practitioner about her persistent cough. Recently, she was laid off from her job at the retail store and lost all benefits. She has had a fever and chills for several days. As the nurse begins the assessment, Mrs. Owens begins to cry and says: "I have no money to pay for medicine or this visit. Please do not order an antibiotic, because I cannot pay for it." The nurse's best response would be which of the following?

A)"I understand your concerns, Mrs.Owens.I have free medicine from donors to give you."
B)"I understand your concerns Mrs.Owens.It looks like you will qualify for Medicaid benefits."
C)"Don't worry Mrs.Owens, I won't prescribe an antibiotic."
D)"Mrs.Owens, perhaps you can be seen in the emergency department.They can give you free antibiotics."

Answer 1

"I understand your concerns Mrs.Owens.It looks like you will qualify for Medicaid benefits."

Question 2

Electronic data interchange (EDI) has been instrumental in facilitating the health care process. Which of the following responses best describes the impact of the EDI?

A)EDI has the potential to eliminate second opinions.
B)EDI interacts with multiple databases.
C)EDI supplies proof of recovery.
D)EDI facilitates the approval of patient claims.

Answer 2

EDI facilitates the approval of patient claims.

Question 3

Which of the following organizations is the umbrella under which all regulatory agencies eventually fall because the health and welfare of the citizens of the nation are ultimately deemed to be federal responsibility?

A)Centers for Disease Control (CDC)
B)The U.S.Department of Health and Human Services (USDHHS)
C)Health and Human Services (HHS)
D)The Federal Employees Health Benefits Program (FEHBP)

Answer 3

The U.S.Department of Health and Human Services (USDHHS)

Question 4

Despite the negative responses by health care providers toward the transition from ICD-9 to ICD-10, which of the following statements is a clear benefit of the transition?

A)Over 100 countries have already adopted the ICD-10 coding system.
B)Coding solutions will be clearly understood by all health professionals.
C)The impact on small physician's practices will be negligible.
D)More nurses will be hired to maintain the systems.

Question 5

On October 1, 2013, the federal government will implement the mandatory transition to the International Classification of Diseases, Tenth Revision (ICD-10). Of the following responses, which is the most reasonable rationale for the upgrade?

A)The ICD-10 is an easier method of coding to use in a complicated health care delivery system.
B)The ICD-10 transition is to better manage the quality of health care data through more precise and accurate diagnostic coding.
C)The ICD-10 initiative is to ensure improved patient outcomes.
D)The ICD-10 has been designed to improve the collection of data at the point of care.

Question 6

Which type of billing codes is used by Medicare to determine the level of severity and per diem rate?

A)POA
B)MS-DRG
C)ICD
D)PPAC

Question 7

Which of the following statements is true about the do-not-pay list?

A)If a patient develops a complication, Medicare will reimburse for all services.
B)If a patient develops complications, Medicaid will reimburse for all services.
C)If a patient has certain complications during the hospital stay, Medicare will not reimburse the hospital at the higher rate for the treatment.
D)If a patient develops a preventable complication, Medicare will demand the immediate transfer of the patient to a different health care setting.

Question 8

Pay for Performance (P4P) otherwise known as value-based purchasing (VBP) system has been developed through ObamaCare. Which of the following are considered goals of this initiative?

A)Financial viability
B)Payment initiatives
C)Effectiveness
D)Ensuring access
E)Smooth transitions

Question 9

The importance of billing codes and reimbursement for services cannot be overstated. Which of the following responses are true regarding accurate code input and claims processing?

A)CPT codes were grouped into services by the first digit followed by four more digits that further described the procedure.
B)The number 9 is reserved for visits related to evaluation and management procedures.
C)The CPT code 99211 is an office visit and used for injections.
D)Two digit modifiers are used to further distinguish services and procedures altering the billing process.
E)Inaccurate code input will delay claims processing.

Question 10

The Centers for Medicare and Medicaid Services (CMS) mandated all providers, insurers and any middlemen involved in the health care industry submission of claims for reimbursement or registering of care, the verifying of eligibility, the precertification of services, or any other client- related information to adhere to a uniform format by October 200
2.This action forced all providers to install_______________________ transmission programs in their billing and medical record systems.Standard Text:

Question 11

The __________________________ was developed by Medicare in an effort to control quality and cost and minimize preventable complications.

Question 12

Medicare is an age or disability based benefit. How is Medicare funded?

A)Through tax dollars
B)Through the state lotteries
C)Through federal earmarks
D)From personal savings

Question 13

Electronic data interchange (EDI) is an effort to help phase out paper claims except under extensive appeal circumstances. The result of this initiative is which of the following?

A)Health care providers were forced to install EDI transmission programs in their billing and medical record systems.
B)A large savings on paper supplies
C)An increased need for assistive software
D)A decrease in the denial of claims

Question 14

What is the rationale the AMA is using to oppose the do-not-pay list?

A)Physicians assert each patient's circumstances are unique and complications cannot always be prevented or explained.
B)The physicians assert this reimbursement ruling is unjust.
C)The physicians assert the do-not-pay list is punitive to health care providers.
D)The physicians assert do-not-pay list minimizes complications.

Question 15

Which of the following statements about Medicare Part A are correct?

A)Medicare Part A has an annual deductible.
B)Medicare Part A covers immunizations.
C)Medicare Part A covers facility related expenses.
D)Medicare Part A covers medical supplies.
E)Medicare Part A is also called the Advantage Plan.

Question 16

President Obama signed into law on March 23, 2010, The Health Care and Education Reconciliation Act of 2010 (Pub.L.111-152, 124Stat.1029), which amended the Patient Protection and Affordable Care Act (PPAC) and further strengthened the federal grip on health care regulation in the United States. Which of the following statements best reflects the intentions of the act?

A)The health care of children under the age of 15 will be covered by local government funds.
B)Veterans from the Iraq War will have all health insurance benefits excluding dental.
C)The act guarantees health insurance for every citizen.
D)The act moves regulation of federal health insurance to the state levels.

Question 17

One of the biggest pitfalls and concerns to health care providers to the transition to the ICD-10 by 2013 is which of the following?

A)Training staff to use the new system efficiently
B)Having enough qualified personnel available to troubleshoot impending issues
C)The need to overcome resistance to change in the health care setting
D)The cost to convert the current systems to accommodate the changes

Question 18

Which of the following responses is not a benefit of Pay for Performance (P4P) legislation?

A)The system rewards health care providers upon good service to consumers.
B)The system rewards physicians and other health care professionals when patients receive good results from that care.
C)Reimbursement is related to quality and efficiency of care provided.
D)Patients will play a more active role in the determination of performance-based payment.

Question 19

The ratification of the Title XVIII and Title XIX Acts in 1965 led to which of the following?

A)The GI Bill
B)State informatics and licensing agencies
C)Medicare and Medicaid
D)Welfare benefits

Question 20

The system called Pay for Performance (P4P) is also known as which of the following?

A)Value-based purchasing (VBP)
B)Diagnostic related groups
C)Children's Health Initiative Program
D)Medicaid

Question 21

As technology is implemented in health care systems, the role of the nurse who has informatics experience and education will be placed in leadership roles to do which of the following?

A)Guide IT technicians
B)Work closely with physicians
C)Spearhead policy reform
D)Develop evidence based practice models
E)Participate in research initiatives

Question 22

The role of the informatics nurse is important to the success of the implementation of the EHR. Which of the following statements is true about the expanded role of the informatics nurse?

A)The informatics nurse has the responsibility of maintaining the compliance procedures of the health care setting.
B)The informatics nurse has the responsibility of analyzing the coding system.
C)The informatics nurse has the responsibility to serve as the liaison between physician and patient and physician and agency.
D)The informatics nurse has the responsibility of creating meaningful use policies.

Question 23

There has been an impact of the Health Insurance Reform Act, also known as The Patient Protection and Affordable Care Act, on system use and design. Which of the following actions was enacted upon the president's signature?

A)Young people can remain on their parents insurance until 24 years old.
B)Children with preexisting conditions are no longer covered.
C)New plans must offer free preventive care.
D)There are lifetime limits on benefits.

Question 24

The effects of the new regulatory and reimbursement laws instigated subtle changes which will have an impact on the physician office as well as outpatient facilities, ancillary services, and hospitals. In order to become, or perhaps soon remain, a Medicare/Medicaid provider, a medical compliance program must be in place. According to the Fox Group's website that includes which of the following measures?

A)Compliance with health and safety laws and regulations
B)Compliance with fraud complaints
C)Compliance with environmental laws and regulations
D)Compliance with human resources laws and regulations
E)Compliance with HIPAA laws and regulations

Question 25

The impact of the mandated technology use has created change throughout the health care community. How has the Affordable Health Care Act affected nursing?

A)Nursing professionals will spend more time at the computer and less time at the bedside.
B)There will be surge in applications for certified nursing assistant positions.
C)There will be a decreased need for point-of-care nurses.
D)There will be an increased need for nurse informatics specialists.

Question 26

Implementing an electronic health record in a small primary care practice can be cost prohibitive. To assist in the cost of the endeavor, the government has done which of the following?

A)Provided loans to physicians to purchase technology
B)Offered physicians stipends if they use the equipment correctly
C)Has given financial aid to larger practices to purchase equipment
D)Has given physicians the equipment to convert to electronic health records

Question 27

Which of the following statements is true about the projected results of the increase in federal and state mandated health care cost reform legislation?

A)The increase in governmental regulations provides for a higher quality of care.
B)Governmental oversight is something that has been lacking in health care over the past several years.
C)The burden of proof is placed on the health care community.
D)The increase in governmental oversight allows for improved outcomes with decreased FTEs.

Question 28

The Patient Protection and Affordable Care Act of March 2010 (PPACA) Section 1561 will, when fully activated by 2014, extend affordable health care to an estimated 32 million more people. Which of the following is not a financial impact of the Act?

A)A need for increased supplies
B)The need to hire more staff
C)The need to monitor patient outcomes
D)The need to hire additional health information technology (HIT) coordinators