Current Status
Not Enrolled
Enroll in this module to get access
Price
Free
Get Started
Healthcare Delivery and Legal Issues
Healthcare Delivery
Healthy People 2020
- Access to health care and improved health care are both major issues for health policy
- Continuance of Healthy People 2000; published in 1990 by the United States Department of Health and Human Services
- Goals
- Increase the quality and years of healthy life
- Eliminate health disparities among Americans
- Document contains hundreds of health objectives based on numerous focus areas
- Objectives relate to equal access, availability, cost, quality of care, etc.
- Used to understand health status of the nation and plan prevention programs
- Individuals, communities, and organizations are responsible for determining how to meet the goals of Healthy People 2020
Reporting Statutes
Require practitioners to report specific health-related information
Vary from state to state but commonly involve:
- Gonorrhea
- Chlamydia
- Syphilis
- HIV
- Tuberculosis
- Animal Bites (Animal control; subsidiary of of the DHHS)
- Suspected Child or Elder Abuse (police via social services)
- Domestic Violence: NPs and PAs are not legally required to report in most states. Supervising physicians are. Involved them if you are not independently practicing!
Navigating the Health Case System for Patients
- Social Services
- Psychiatric Services
- Police
- Security Officers
- Physical/Occupational Therapy
- Occupational Therapy
Healthcare Finance
Health Care Financing
Coding
- Evaluation and Management (E/M) codes identify the level of care provided
- Codes match the level of service provided to the complexity of the presenting patient problem
Billing
- The mechanism for sending the patient a bill to be paid. Can come from the practice, hospital, or third-party billing company
Reimbursement
- The amount collected from the payer after payment has been made
Third Party Payers
- Payers can be the patient themselves, or third party payers such as insurance companies
Categories of Third Party Payers
Medicare
- Sets the standard for reimbursement and cutting costs
Medicaid
Commercial indemnity insurers
Commercial management organizations
- Health maintenance organizations (HMOs)
Businesses or schools wanting health care services for employees or students
Appropriate Level Physical Exam Documentation to Determine Levels of E/M Services
Problem Focused
- A limited examination of the affected body area or organ system
Expanded Problem Focused
- A limited examination of the affected body area or organ system and any other symptomatic or related body areas(s) or organ system(s)
Detailed
- An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
Comprehensive
- A general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s)
Types of Medicare
Medicare A
- Covers inpatient/hospitalization, skilled nursing facility services, home health services, and/or hospice associated with the inpatient event
- Most individuals qualify to receive benefits at 65 years of age
Medicare B
- Covers physician services, outpatient hospital services, laboratory and diagnostic procedures, medical equipment, and some home health services
- Supplemental medical insurance requiring recipients to pay a premium
- Advanced Practice Providers receive 85% of physician reimbursement for services in collaboration with a physician
- Medicare pays 80% of the patient’s bill for physician services and the patient pays 20% (copay)
Medicare C (Medicare Advantage)
- Combined benefits of Medicare A and B
- Patients entitled to Medicare part A and enrolled in part B are eligible to receive all of their health care services through one of the provider organizations under part C (e.g. HMOs, PPOs, etc)
Medicare D (Limited Prescription Drug Coverage)
- Plans offered by insurance and other private companies are approved by Medicare
- Monthly premium required
- Copay on each prescription is required
- Penalty may be applicable if not enrolled when first eligible
- Assistance is available for people with limited income and resources
Services that Do NOT Meet Medicare’s Definition of “Physician Services”
Medicare Rules for NPs and PAs
To qualify to be a Medicare provider, an APP must:
- Hold a state license
- Be certified by a recognized national certifying body
- Hold at least a master’s degree in nursing or physician assistant studies
- Meet Medicare qualification requirements
- Accept Medicare payment
- No facility or other provider charges or is paid with respect to the furnishing of services, which include:
- “Physician Services” for which a physician can bill Medicare
- Performed in collaboration with a physician
- Within the APP’s scope of practice as defined by state law
Incident-To Billing
Services billed under the physician’s provider number to get the full physician fee (100%) given the following rules:
The services are
- An integral, although incidental, part of the physician’s professional service
- Commonly rendered without charge or included in the physician’s bill
- Of a type commonly furnished in physician’s offices or clinics
- Furnished under the physician’s direct personal supervision and are furnished by the physician or by an individual who is an employee of independent contractor of the physician. Direct supervision does not require the physician’s presence in the same room but the physician must be present in the same office suite and immediately available
- The physician must perform “the initial service and subsequent services of a frequency which reflect his or her active participation in the management of the course of treatment”
- The physician/other provider under whose name and number the bill is submitted must be the individual present in the office suite when the service is provided
- Incident-to billing is not allowed in the hospital setting
- An APP must bill under his/her provider number
- An APP may bill for an assistant’s work (e.g. performing an EKG) under their provider number as long as the rules for incident-to billing are followed
Other Rules for Billing
- Physicians and APPs may see a patient on the same day for their services, but cannot both bill for the same services. Care must be coordinated.
- For inpatients, physicians and APPs must decide for which party (i.e. the APP or the physician) should bill, given the amount of services rendered by each on given day.
- For home APP visits billable for Medicare A services, APPs do not need a physician’s order to bill under their provider number, unless the APP is providing services exclusively
Medicaid
- Federally supported, state administered program for low-income families and individuals
- Differs from state to state
- Medicaid payments are made after other insurance or third party payments have been made
Case Management
- Involves a comprehensive and systematic approach to provide quality care
- Purpose
- Mobilize, monitor, and control resources that a patient uses during a course of an illness while balancing quality and cost
Quality Assurance and Improvement
Quality Assurance/Quality Improvement (QA/QI) and Continuous Process Improvement (CPI)
A management process of monitoring, evaluating, continuous review, and improving the quality in providing healthcare
Quality Assurance
- A process for evaluating the care of patients using established standards of care to ensure quality
- Based on the methodology developed by Demand and tested in Japanese industry that quality cane improved by continually monitoring structure, process, and outcome standards
Structures
- Inputs into care such as resources, equipment, or numbers and qualifications of staff
Processes of care
- Includes assessments, planning, performing treatments, and managing complications
Outcomes
- Include complications, adverse events, short term results of treatment and long term results of patient health and functioning
- Used to assess, monitor, and improve care provided to patients
- Components include monitoring of care quality, career appropriateness, effectiveness of care, cost of care, self-regulation, and peer review to ensure compliance to care standards
Steps of CQI/QA from the Joint Commission
Quality planning
- Developing a quality management plan which assigns responsibility for degree for involvement
- Delineate scope of care
- Identify important aspects of care
- Identify indicators related to aspects of care
- Establish thresholds for evaluation related to the indicators
- Collect and organize data
- Evaluate care when thresholds are reached
- Take action to improve care
- Assess the effectiveness of the action and document improvement
- Communicate relevant information
- Critical Path
- Contains key patient care activities and time frames for those activities which are needed for a specific case type or diagnostic-related group (DRG)
- Care Map
- A newer version of the critical path and a blueprint for planning and managing care delivered by all disciplines
- The care map contains a critical path section plus a section that identifies common problems encountered by patients of a specific case type, the day-to-day goals that the patient must achieve, and the final desired clinical outcomes
- Monitoring of outcomes of care is a very important goal
Root Cause Analysis
- A tool for identifying prevention strategies to ensure safety
- A process that is part of the effort to build a culture of safety and move beyond the culture of blame
- Involves and incorporates
- Inter-disciplinary experts from the frontline services
- Those who are the most familiar with a situation
- Continually digging deeper by asking “why” at each level of cause and effect
- Identifying changes that need to be made to systems
- A process that is as impartial as possible
Sentinel Events
- Unexpected occurrences involving death or serious physical or psychological injury or the risk thereof
- Serious injury specifically includes loss of limb or function
- The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome
- Such events are called “sentinel” because these signal the need for immediate investigation and response
- The terms “sentinel event” and “medical error” are not synonymous – not all sentinel events occur because of an error and not all errors result in sentinel events
- In response to a sentinel event (such as falls in a hospital) clinicians and institutions are expected to conduct a root cause analysis.
Advanced Directives Versus Living Wills
Advance Directive
- Type of advance directive that may (or may not) include a living will and/or specifications regarding durable power of attorney in one or two separate documents
Healthcare Directive
- Written statement of a patient’s intent regarding medical treatment.
- The Patient Self-Determination Act of 1990 requires that all patients entering a hospital should be advised of their right to execute an advance direction
Living Will
- Written compilation of statements in document format that specifies which life-prolonging measures one does and does not want to be taken if he/she becomes incapacitated
- In the United States, most states recognize living wills as long as the will is specific enough and addresses the problem at hand
- Living wills often include granting durable power of attorney to a significant other to act as a proxy/agent/attorney-in-fact of the patient in making healthcare decisions should the patient become incapacitated. Essentially, the proxy is responsible for articulating the patient’s advance directive.
- Power of attorney must usually be in writing before it will be honored by most institutions such as hospitals, banks, etc.
Legal Terms
Legal Terms
Liability
- The legal responsibility that a provider has for actions that fail to meet the standard of care, resulting in actual or potential harm to a patient
- Standards of care are used as criteria to measure whether negligence has occurred
Negligence
- Failure of an individual to do what a reasonable person would do, resulting in injury to the patient
Malpractice
- Failure of a professional to render services with the degree of care, diligence, and precaution that another member of the same profession under similar circumstances would render to prevent injury to someone else
- May involve:
- Professional misconduct
- Unreasonable lack of skill
- Illegal or immoral conduct
- Other allegations resulting in harm to a patient
- Malpractice insurance does not cover an APP from charges of practicing medicine without a license if the APP is practicing outside of the local scope of practice for that state
Assault
- An intentional act by one person that creates an apprehension in another of an imminent harmful or offensive contact
- An assault is carried out by a threat of bodily harm coupled with an apparent, present ability to cause the harm
- Examples: shaking a fist in the air in the direction of another person, making the motion to inject someone against their will, etc.
Battery
- An illegal, willful, angry, violent, or negligent striking of a person, their clothes, or anything with which they are in contact
- One can commit battery on an unconsciousness person, but not assault
Defamation
- A communication that causes someone to suffer a damaged reputation
Libel
- Defamation by written material
Slander
- Spoken defamation spoken to other than the defamed party
Involuntary commitment
- In most states, there is a duty to commit someone who is in danger of hurting themselves or others as a result of mental illness
- An APP is potentially liable if a patient is discharged while in danger of hurting himself or others
Use of restraints
- It is legal to forcefully restrain someone to prevent a patient from harming himself or others
- The APP must document the exact reason/rationale for why restraints are being ordered
- An APP may be liable if excessive restraints are employed, the exact reason for using restraints is not documented, or safety checks of the restraints are not charted
Good Samaritan Statutes
- Protect healthcare providers from law suits who aid at the scene of an accident and render reasonable, emergency care, within their scope of practice
