Chapter 20
Question 1
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?
1. The health care of children under the age of 15 will be covered by local government funds.
2. Veterans from the Iraq War will have all health insurance benefits excluding dental.
3. The act guarantees health insurance for every citizen.
4. The act moves regulation of federal health insurance to the state levels.
Correct Answer: 3
Rationale 1:
This statement is incorrect. The Health Care and Education Reconciliation Act of 2010
(HCERA) does not specifically address the funding of children's healthcare by local
government funds.
Rationale 2:
This statement is incorrect. While the act may have implications for veterans' healthcare, it
does not specifically mention veterans from the Iraq War or their health insurance benefits.
Rationale 3:
This statement is correct. One of the primary intentions of The Health Care and Education
Reconciliation Act of 2010 (HCERA) was to expand access to health insurance coverage and
guarantee access to healthcare for every citizen through provisions such as Medicaid
expansion, health insurance exchanges, and subsidies for purchasing insurance.
Rationale 4:
This statement is incorrect. The act aimed to strengthen federal regulation and oversight of
health care, rather than transferring regulation to the state levels.
Question 2
The ratification of the Title XVIII and Title XIX Acts in 1965 led to which of the following?
1. The GI Bill
2. State informatics and licensing agencies
3. Medicare and Medicaid
4. Welfare benefits
Correct Answer: 3
Rationale 1:
This statement is incorrect. The GI Bill is a separate piece of legislation that primarily
provides education and training benefits to veterans and their dependents, and it was not
directly related to the ratification of Title XVIII (Medicare) and Title XIX (Medicaid) Acts in
1965.
Rationale 2:
This statement is incorrect. While the establishment of Medicare and Medicaid may have
influenced the development of state healthcare agencies and regulations, it did not directly
lead to the creation of state informatics and licensing agencies.
Rationale 3:
This statement is correct. The ratification of Title XVIII (Medicare) and Title XIX (Medicaid)
Acts in 1965 established the Medicare and Medicaid programs, which provide healthcare
coverage for elderly and low-income individuals, respectively. These programs significantly
expanded access to healthcare services in the United States.
Rationale 4:
This statement is incorrect. While Medicare and Medicaid provide healthcare benefits to
eligible individuals, they are separate from welfare programs, which typically provide
financial assistance to individuals and families in need.
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?
1. Centers for Disease Control (CDC)
2. The U.S. Department of Health and Human Services (USDHHS)
3. Health and Human Services (HHS)
4. The Federal Employees Health Benefits Program (FEHBP)
Correct Answer: 2
Rationale 1:
The Centers for Disease Control and Prevention (CDC) is a federal agency responsible for
protecting public health and safety through the control and prevention of disease, injury, and
disability. While the CDC plays a significant role in public health, it is not the overarching
umbrella organization for all regulatory agencies.
Rationale 2:
The U.S. Department of Health and Human Services (USDHHS) is the federal executive
department responsible for enhancing the health and well-being of Americans by providing
effective health and human services and fostering advances in medicine, public health, and
social services. It serves as the umbrella under which all regulatory agencies eventually fall
because it oversees a wide range of agencies and programs related to health and welfare.
Rationale 3:
"Health and Human Services (HHS)" is not a specific organization but rather a general term
often used to refer to the broader field of health and human services. While it encompasses
the activities and responsibilities of various agencies and programs related to health and
welfare, it does not represent a singular umbrella organization.
Rationale 4:
The Federal Employees Health Benefits Program (FEHBP) is a government program that
provides health insurance to federal employees, retirees, and their eligible family members.
While it is an important program for federal employees, it does not serve as the umbrella
organization for all regulatory agencies responsible for the health and welfare of the nation's
citizens.
Question 4
The system called Pay for Performance (P4P) is also known as which of the following?
1. Value-based purchasing (VBP)
2. Diagnostic related groups
3. Children's Health Initiative Program
4. Medicaid
Correct Answer: 1
Rationale 1:
Value-based purchasing (VBP) is another term used to describe the Pay for Performance
(P4P) system. In both approaches, healthcare providers are incentivized or reimbursed based
on the quality, efficiency, and outcomes of care provided rather than solely on the volume or
number of services rendered.
Rationale 2:
Diagnostic related groups (DRGs) are a different payment system used in healthcare,
particularly in hospital reimbursement, where patients with similar diagnoses and treatments
are grouped together for billing purposes. While DRGs are related to payment mechanisms,
they are not synonymous with Pay for Performance.
Rationale 3:
The Children's Health Initiative Program is a specific program aimed at providing healthcare
coverage and services to children. It is not directly related to Pay for Performance or Valuebased purchasing.
Rationale 4:
Medicaid is a government program that provides healthcare coverage to low-income
individuals and families. While Medicaid may incorporate aspects of value-based purchasing
or pay for performance in its payment models, it is not synonymous with the term Pay for
Performance or Value-based purchasing.
Question 5
Medicare is an age or disability-based benefit. How is Medicare funded?
1. Through tax dollars
2. Through state lotteries
3. Through federal earmarks
4. From personal savings
Correct Answer: 1
Rationale 1:
Medicare is primarily funded through tax dollars, including payroll taxes paid by employees
and employers, taxes on Social Security benefits, income taxes on high-income individuals,
and premiums paid by beneficiaries. These tax revenues contribute to the Medicare Trust
Funds, which help finance the program's expenses.
Rationale 2:
State lotteries do not directly fund Medicare. While some states allocate a portion of lottery
revenues to specific programs such as education or infrastructure, Medicare is primarily
funded through federal tax revenues.
Rationale 3:
Federal earmarks are specific allocations of federal funds for particular projects or programs.
While Medicare receives funding from the federal government, it is not typically funded
through earmarks.
Rationale 4:
Medicare is not funded from personal savings. Instead, it operates as a social insurance
program, where current contributions from taxpayers fund healthcare benefits for eligible
individuals, including those who are aged or disabled.
Question 6
Which of the following statements about Medicare Part A are correct?
1. Medicare Part A has an annual deductible.
2. Medicare Part A covers immunizations.
3. Medicare Part A covers facility-related expenses.
4. Medicare Part A covers medical supplies.
5. Medicare Part A is also called the Advantage Plan.
Correct Answer: 1, 3
Rationale 1:
Medicare Part A does have an annual deductible. This deductible applies to inpatient hospital
stays, skilled nursing facility stays, hospice care, and some home health care services.
Rationale 2:
This statement is incorrect. Medicare Part A generally does not cover routine immunizations.
However, it does cover certain vaccinations if they are deemed medically necessary during a
covered inpatient hospital stay or as part of a skilled nursing facility stay.
Rationale 3:
Medicare Part A covers facility-related expenses, including inpatient hospital stays, skilled
nursing facility stays, hospice care, and some home health care services. These services are
primarily focused on care provided in a facility setting rather than outpatient or medical
supply coverage.
Rationale 4:
This statement is incorrect. While Medicare Part A covers certain medical services provided
in facilities, it generally does not cover medical supplies directly. Coverage for medical
supplies may be available through other parts of Medicare, such as Part B or Part D, or
through supplemental insurance plans.
Rationale 5:
This statement is incorrect. Medicare Part A is not referred to as the Advantage Plan. The
Advantage Plan typically refers to Medicare Part C, which is an alternative way to receive
Medicare benefits through private insurance companies approved by Medicare.
Question 7
Mrs. 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?
1. "I understand your concerns, Mrs. Owens. I have free medicine from donors to give you."
2. "I understand your concerns Mrs. Owens. It looks like you will qualify for Medicaid
benefits."
3. "Don't worry Mrs. Owens, I won't prescribe an antibiotic."
4. "Mrs. Owens, perhaps you can be seen in the emergency department. They can give you
free antibiotics."
Correct Answer: 2
Rationale 1:
While the intention to provide free medicine to Mrs. Owens is noble, relying on medicine
from donors may not be a sustainable or reliable solution for her ongoing healthcare needs.
Additionally, the availability of such donated medicine may be limited, and it does not
address Mrs. Owens' long-term access to healthcare services.
Rationale 2:
This response is the most appropriate because it addresses Mrs. Owens' immediate concern
about the cost of the visit and medication. Informing her that she may qualify for Medicaid
benefits offers a potential solution to her financial barriers to healthcare access. Medicaid
provides health coverage to eligible low-income individuals and families, which could help
Mrs. Owens afford the visit and necessary medications.
Rationale 3:
While this response acknowledges Mrs. Owens' concerns, it does not offer a solution to
address her financial barriers to healthcare access. Simply refraining from prescribing an
antibiotic may leave Mrs. Owens without appropriate treatment for her condition.
Rationale 4:
Suggesting that Mrs. Owens go to the emergency department for free antibiotics may not be
the most appropriate response. Emergency departments are typically reserved for acute or
life-threatening conditions, and Mrs. Owens' persistent cough may not warrant emergency
care. Additionally, relying on emergency departments for non-emergency healthcare needs
can strain resources and may not address the underlying issue of Mrs. Owens' lack of access
to primary care.
Question 8
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?
1. EDI has the potential to eliminate second opinions.
2. EDI interacts with multiple databases.
3. EDI supplies proof of recovery.
4. EDI facilitates the approval of patient claims.
Correct Answer: 4
Rationale 1:
This statement is incorrect. EDI does not eliminate the need for second opinions. Second
opinions are sought by patients or recommended by healthcare providers to ensure accuracy
and thoroughness in diagnosis and treatment decisions. EDI primarily involves the electronic
exchange of healthcare information between different entities but does not impact the need
for second opinions.
Rationale 2:
This statement is incorrect. While EDI can interact with multiple databases to exchange
healthcare information electronically, its primary function is not specifically focused on
database interaction. EDI is more concerned with the electronic exchange of standardized
data between different computer systems in a format that is easily understood and processed.
Rationale 3:
This statement is incorrect. EDI itself does not supply proof of recovery. Proof of recovery
typically refers to documentation or evidence demonstrating that a patient has successfully
recovered from an illness, injury, or medical procedure. EDI primarily facilitates the
electronic exchange of information related to patient claims, administrative transactions, and
other healthcare processes.
Rationale 4:
This statement is correct. One of the key impacts of EDI in healthcare is facilitating the
approval of patient claims. EDI enables the electronic submission of claims information from
healthcare providers to insurance payers or other relevant entities, streamlining the claims
processing workflow and reducing the time and effort required for claim approval and
reimbursement.
Question 9
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 2002. This action forced
all providers to install _______________ transmission programs in their billing and medical
record systems.
Correct Answer: Electronic Data Interchange (EDI)
Rationale:
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 2002. This action forced
all providers to install Electronic Data Interchange (EDI) transmission programs in their
billing and medical record systems and has altered the methods of communication for all
health care professionals.
Question 10
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?
1. Health care providers were forced to install EDI transmission programs in their billing and
medical record systems.
2. A large savings on paper supplies
3. An increased need for assistive software
4. A decrease in the denial of claims
Correct Answer: 1
Rationale 1:
This statement is correct. As part of the transition to electronic claims submission, healthcare
providers were required to implement EDI transmission programs in their billing and medical
record systems. These programs facilitate the electronic exchange of standardized healthcare
information between providers and payers, reducing the reliance on paper-based claims
submission processes.
Rationale 2:
This statement is incorrect. While the adoption of EDI may lead to some savings on paper
supplies due to a reduction in paper claims, the primary motivation for transitioning to
electronic claims submission is not specifically focused on saving paper supplies.
Rationale 3:
This statement is incorrect. While the adoption of EDI may require the use of assistive
software to facilitate electronic claims submission and processing, it does not necessarily
result in an increased need for assistive software beyond what is already utilized in healthcare
information technology systems.
Rationale 4:
This statement is incorrect. While EDI may contribute to more accurate and efficient claims
processing, its implementation alone does not guarantee a decrease in the denial of claims.
Claim denial rates can be influenced by various factors, including the accuracy of the
information submitted, adherence to coding and documentation guidelines, and payer
policies.
Question 11
Which of the following responses is not a benefit of Pay for Performance (P4P) legislation?
1. The system rewards health care providers upon good service to consumers.
2. The system rewards physicians and other health care professionals when patients receive
good results from that care.
3. Reimbursement is related to quality and efficiency of care provided.
4. Patients will play a more active role in the determination of performance-based payment.
Correct Answer: 2
Rationale 1:
This statement is a benefit of Pay for Performance (P4P) legislation. P4P programs
incentivize healthcare providers to deliver high-quality care by rewarding them for good
service to consumers, which can lead to improved patient outcomes and satisfaction.
Rationale 2:
This statement is incorrect. While P4P programs aim to improve patient outcomes and quality
of care, they do not directly reward physicians and other healthcare professionals based on
patients' results from that care. Instead, reimbursement in P4P programs is typically tied to
the quality and efficiency of care provided, measured by predefined performance metrics.
Rationale 3:
This statement is a benefit of P4P legislation. By linking reimbursement to the quality and
efficiency of care provided, P4P programs encourage healthcare providers to deliver higherquality care and adopt practices that improve patient outcomes while also controlling costs.
Rationale 4:
This statement is a potential benefit of P4P legislation. In some P4P programs, patients may
play a more active role in the determination of performance-based payment through
mechanisms such as patient satisfaction surveys or shared decision-making processes.
Increased patient involvement can enhance accountability and transparency in healthcare
delivery.
Question 12
Pay for Performance (P4P), otherwise known as value-based purchasing (VBP) system, has
been developed through various healthcare initiatives, not solely through ObamaCare.
However, it aligns with the broader goals of healthcare reform efforts. The goals of this
initiative include:
1. Financial viability: P4P aims to incentivize healthcare providers to deliver high-quality
care efficiently, thereby promoting financial sustainability within the healthcare system.
2. Payment initiatives: P4P encourages the implementation of payment models that reward
providers based on the quality and outcomes of care rather than just the quantity of services
provided.
3. Effectiveness: P4P seeks to improve the effectiveness of healthcare delivery by focusing on
outcomes, patient satisfaction, and evidence-based practices.
4. Ensuring access: P4P aims to ensure that patients have access to high-quality healthcare
services by incentivizing providers to meet quality standards and improve patient outcomes.
5. Smooth transitions: While improving care transitions may be an important aspect of
healthcare quality improvement initiatives, it is not explicitly a goal of P4P or VBP systems.
Correct Answer: 1, 2, 3, 4
Rationale 1:
Financial viability is a key goal of P4P initiatives, as they aim to align financial incentives
with the delivery of high-quality care to ensure the long-term sustainability of healthcare
systems.
Rationale 2:
Payment initiatives are central to P4P programs, as they involve structuring reimbursement
mechanisms to reward providers based on their performance on quality and outcome
measures.
Rationale 3:
Effectiveness in healthcare delivery is a fundamental goal of P4P programs, as they aim to
improve patient outcomes, enhance the quality of care, and promote evidence-based
practices.
Rationale 4:
Ensuring access to high-quality healthcare services for all patients is a key objective of P4P
initiatives, as they aim to incentivize providers to improve care quality and outcomes, which
can ultimately benefit patients by enhancing their access to effective healthcare.
Question 13
Of the following responses, which is the most reasonable rationale for the upgrade to the
International Classification of Diseases, Tenth Revision (ICD-10)?
1. The ICD-10 is an easier method of coding to use in a complicated health care delivery
system.
2. The ICD-10 transition is to better manage the quality of health care data through more
precise and accurate diagnostic coding.
3. The ICD-10 initiative is to ensure improved patient outcomes.
4. The ICD-10 has been designed to improve the collection of data at the point of care.
Correct Answer: 2
Rationale 1:
This rationale is not accurate. Transitioning to ICD-10 involves a more extensive and detailed
coding system compared to its predecessor, ICD-9. While ICD-10 provides more specificity
in coding, it is not necessarily easier to use, especially in a complex healthcare delivery
system.
Rationale 2:
This rationale is the most reasonable explanation for the upgrade to ICD-10. The transition
aims to improve the quality of healthcare data by adopting a coding system that allows for
more precise and accurate diagnostic coding. Enhanced coding accuracy can lead to better
documentation of patient conditions, improved tracking of diseases and public health trends,
and more accurate reimbursement for healthcare services.
Rationale 3:
While the implementation of ICD-10 may indirectly contribute to improved patient outcomes
by enabling better tracking and management of health conditions, this is not the primary goal
of transitioning to ICD-10. The main focus is on enhancing the quality and accuracy of
diagnostic coding.
Rationale 4:
While ICD-10 does provide opportunities for improved data collection at the point of care
due to its expanded code set and granularity, this is not the primary rationale for the
transition. The primary goal is to enhance the quality and accuracy of diagnostic coding to
better manage healthcare data.
Question 14
Question: 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?
1. Training staff to use the new system efficiently
2. Having enough qualified personnel available to troubleshoot impending issues
3. The need to overcome resistance to change in the health care setting
4. The cost to convert the current systems to accommodate the changes
Correct Answer: 4
Rationale 1:
While training staff to use the new system efficiently is indeed a challenge during the
transition to ICD-10, it may not be the biggest concern. Training programs can be
implemented to educate staff, and resources can be allocated for this purpose. However, the
cost associated with converting the current systems is often a more significant barrier, as it
involves updating or replacing existing technology, which can be expensive and timeconsuming.
Rationale 2:
Having enough qualified personnel available to troubleshoot impending issues is crucial for a
smooth transition to ICD-10. However, it is not typically cited as one of the biggest pitfalls or
concerns. While the availability of skilled personnel is important, it is often overshadowed by
other challenges such as cost and resistance to change.
Rationale 3:
Resistance to change is indeed a significant challenge in any organizational transition,
including the adoption of ICD-10. However, while it can impede progress and create
obstacles, it may not be considered the single biggest pitfall. Resistance can be addressed
through effective change management strategies and communication, whereas the cost of
converting systems may present a more immediate and tangible barrier.
Rationale 4:
The cost to convert the current systems to accommodate the changes imposed by ICD-10 is
often cited as one of the biggest pitfalls and concerns for health care providers. This includes
not only the expenses associated with upgrading or replacing existing software and
infrastructure but also the potential revenue loss due to disruptions in billing and coding
processes. The financial burden of implementation can be substantial, making it a significant
barrier for many organizations.
Question 15
Question: 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?
1. Over 100 countries have already adopted the ICD-10 coding system.
2. Coding solutions will be clearly understood by all health professionals.
3. The impact on small physician's practices will be negligible.
4. More nurses will be hired to maintain the systems.
Correct Answer: 1
Rationale 1:
This statement highlights a clear benefit of the transition to ICD-10. The fact that over 100
countries have already adopted the ICD-10 coding system indicates its widespread
acceptance and usage worldwide. This adoption fosters standardization and compatibility
across international healthcare systems, which can facilitate collaboration, research, and data
exchange on a global scale. It also implies that the transition to ICD-10 is part of a larger
trend towards modernizing healthcare coding and classification systems to keep pace with
evolving medical practices and technologies.
Rationale 2:
While the transition to ICD-10 aims to improve coding accuracy and specificity, it does not
guarantee that coding solutions will be clearly understood by all health professionals. The
complexity of the new coding system may require ongoing education and training for
healthcare professionals to effectively utilize it, and comprehension may vary among
individuals based on their familiarity and experience with the system.
Rationale 3:
The impact on small physician's practices may not necessarily be negligible. Depending on
various factors such as the resources available, the readiness of the practice, and the level of
support provided during the transition, small practices may face significant challenges in
adapting to the new coding system. The transition process could require investments in
training, software upgrades, and workflow adjustments, which may pose financial and
operational burdens for small practices.
Rationale 4:
While the transition to ICD-10 may necessitate additional support staff or resources to
manage coding and documentation requirements, it does not guarantee that more nurses will
be hired specifically for maintaining the systems. The allocation of resources, including
staffing decisions, would depend on the individual needs and priorities of healthcare
organizations, and hiring decisions would likely be based on various factors beyond just the
transition to ICD-10.
Question 16
Question: Which type of billing codes is used by Medicare to determine the level of severity
and per diem rate?
1. POA
2. MS-DRG
3. ICD
4. PPAC
Correct Answer: 2
Rationale 1:
Present on Admission (POA) indicators are used to identify conditions present at the time of
inpatient admission. While POA indicators are important for tracking the timing of certain
conditions, they are not directly used by Medicare to determine the level of severity and per
diem rate.
Rationale 2:
Medicare Severity-Diagnosis Related Groups (MS-DRGs) are the type of billing codes used
by Medicare to determine the level of severity and per diem rate for inpatient hospital stays.
MS-DRGs categorize patients into groups based on their diagnoses, procedures, age, sex,
discharge status, and other factors to assign a payment weight that reflects the expected
resource consumption and severity of the case.
Rationale 3:
The International Classification of Diseases (ICD) is a standardized system for classifying
and coding diagnoses, symptoms, and procedures used in medical records and billing. While
ICD codes are essential for describing patient conditions and treatments, they are not directly
used by Medicare to determine the level of severity and per diem rate. However, MS-DRGs
are based on ICD codes.
Rationale 4:
The PPAC (Patient Protection and Affordable Care) Act is a legislative act related to
healthcare reform, but it is not specifically used by Medicare to determine the level of
severity and per diem rate. Medicare primarily relies on MS-DRGs for this purpose.
Question 17
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?
1. CPT codes were grouped into services by the first digit followed by four more digits that
further described the procedure.
2. The number 9 is reserved for visits related to evaluation and management procedures.
3. The CPT code 99211 is an office visit and used for injections.
4. Two digit modifiers are used to further distinguish services and procedures altering the
billing process.
5. Inaccurate code input will delay claims processing.
Correct Answer: 1,2,3,4,5
Rationale 1:
CPT (Current Procedural Terminology) codes indeed consist of five digits. The first digit
represents the category of the procedure, and the subsequent four digits provide further
specificity and description of the procedure. This categorization helps in grouping similar
procedures together for billing and reimbursement purposes.
Rationale 2:
The statement that the number 9 is reserved for visits related to evaluation and management
(E/M) procedures is accurate. In the CPT code system, codes in the 90000 series are indeed
designated for E/M services, which include office visits, consultations, and other encounters
where evaluation and management of the patient's condition are the primary focus.
Rationale 3:
The CPT code 99211 is used for office visits that are primarily for the administration of
injections or other minor procedures. It is a low-level E/M code often used for
straightforward encounters that do not require significant physician involvement. This
statement accurately describes the use of CPT code 99211.
Rationale 4:
Two-digit modifiers are commonly used in medical billing to provide additional information
or clarification about a service or procedure performed. These modifiers are appended to the
main CPT or HCPCS (Healthcare Common Procedure Coding System) code to further
distinguish aspects such as the location, extent, or circumstances of the service rendered.
Modifiers help ensure accurate billing and reimbursement by accurately reflecting the
specific circumstances of the service provided.
Rationale 5:
Inaccurate code input can indeed lead to delays in claims processing. Incorrect or improperly
applied codes may trigger claim denials, require additional review or clarification from
payers, or result in payment delays while discrepancies are resolved. Therefore, ensuring the
accuracy of code input is crucial for timely and efficient claims processing and
reimbursement.
Question 18
The __________________________ was developed by Medicare in an effort to control
quality and cost and minimize preventable complications.
Correct Answer: Do Not Pay list
Rationale:
In an effort to control the quality and cost of health care, Medicare developed a "Do Not Pay"
list for preventable complications.
Question 19
Which of the following statements is true about the do-not-pay list?
1. If a patient develops a complication, Medicare will reimburse for all services.
2. If a patient develops complications, Medicaid will reimburse for all services.
3. If a patient has certain complications during the hospital stay, Medicare will not reimburse
the hospital at the higher rate for the treatment.
4. If a patient develops a preventable complication, Medicare will demand the immediate
transfer of the patient to a different health care setting.
Correct Answer: 3
Rationale 1:
This statement is incorrect. Medicare does not reimburse for all services if a patient develops
a complication. The reimbursement may be affected based on various factors, including the
nature of the complication and whether it is considered preventable.
Rationale 2:
This statement is incorrect. The presence of complications does not guarantee reimbursement
for all services by Medicaid. Medicaid reimbursement policies may vary by state and may be
influenced by factors such as the type and preventability of the complications.
Rationale 3:
This statement is true. The do-not-pay list, also known as the Hospital-Acquired Conditions
(HACs) list, includes certain complications or conditions that are deemed preventable and
should not occur during a hospital stay. If a patient develops one of these conditions,
Medicare may not reimburse the hospital at the higher rate for treating the condition. This
serves as an incentive for hospitals to focus on preventing these complications and improving
patient safety.
Rationale 4:
This statement is incorrect. While Medicare's policies aim to prevent and reduce preventable
complications, they do not typically involve demanding the immediate transfer of patients to
a different healthcare setting if a preventable complication occurs. Instead, efforts are focused
on preventing such complications through quality improvement initiatives and financial
incentives.
Question 20
What is the rationale the AMA is using to oppose the do-not-pay list?
1. Physicians assert each patient's circumstances are unique and complications cannot always
be prevented or explained.
2. The physicians assert this reimbursement ruling is unjust.
3. The physicians assert the do-not-pay list is punitive to health care providers.
4. The physicians assert do-not-pay list minimizes complications.
Correct Answer: 1
Rationale 1:
The rationale provided by the American Medical Association (AMA) to oppose the do-notpay list is that physicians assert each patient's circumstances are unique, and complications
cannot always be prevented or explained. This argument suggests that while efforts should be
made to minimize complications, there are situations where they may occur despite
appropriate care and intervention. Physicians argue that penalizing hospitals for these
occurrences may be unfair and fail to account for the complexities of patient care and medical
practice.
Rationale 2:
While physicians may indeed assert that the reimbursement ruling associated with the do-notpay list is unjust, this is not the primary rationale typically cited by the AMA for opposing it.
The focus of the opposition is more on the unique circumstances of patient care and the
challenges in preventing all complications rather than solely on the perceived injustice of the
reimbursement ruling.
Rationale 3:
Physicians may argue that the do-not-pay list is punitive to healthcare providers, but this
sentiment alone does not encapsulate the comprehensive rationale typically provided by the
AMA. The opposition is based on broader considerations related to patient care, medical
practice, and the complexities of the healthcare system rather than solely on the perceived
punitive nature of the list.
Rationale 4:
The assertion that the do-not-pay list minimizes complications is not typically part of the
rationale used by the AMA to oppose it. In fact, the AMA's opposition often stems from the
recognition that while efforts should be made to minimize complications, there are limitations
to what can be achieved in terms of prevention, particularly given the diversity of patient
populations and medical conditions.
Question 21
Which of the following statements is true about the projected results of the increase in federal
and state mandated health care cost reform legislation?
1. The increase in governmental regulations provides for a higher quality of care.
2. Governmental oversight is something that has been lacking in health care over the past
several years.
3. The burden of proof is placed on the health care community.
4. The increase in governmental oversight allows for improved outcomes with decreased
FTEs.
Correct Answer: 3
Rationale 1:
This statement is not necessarily true. While increased governmental regulations may aim to
improve the quality of care by standardizing practices and ensuring compliance with
established guidelines, it does not guarantee a higher quality of care. The impact of regulatory
reforms on care quality can vary depending on various factors, including the effectiveness of
implementation, enforcement mechanisms, and unintended consequences.
Rationale 2:
Governmental oversight in healthcare has been present for many years, although opinions
may differ on its effectiveness or sufficiency. It is not accurate to suggest that governmental
oversight has been lacking over the past several years. However, the effectiveness of
oversight and the need for reform are subjects of ongoing debate and discussion.
Rationale 3:
This statement is true. With increased federal and state mandated health care cost reform
legislation, the burden of proof is often placed on the healthcare community to demonstrate
compliance with regulatory requirements. Healthcare providers may be required to meet
certain standards, report data, or implement specific practices to ensure adherence to
regulatory mandates.
Rationale 4:
While increased governmental oversight may lead to improved outcomes by promoting
adherence to best practices and quality standards, it is unlikely to result in decreased FullTime Equivalents (FTEs) in healthcare settings. In fact, regulatory compliance often requires
additional administrative staff, resources, and time to ensure adherence to regulatory
requirements, which may increase rather than decrease the need for FTEs.
Question 22
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?
1. Young people can remain on their parents insurance until 24 years old.
2. Children with preexisting conditions are no longer covered.
3. New plans must offer free preventive care.
4. There are lifetime limits on benefits.
Correct Answer: 3
Rationale 1:
This statement is incorrect. The Affordable Care Act (ACA) allows young adults to remain on
their parents' health insurance plans until they turn 26 years old, not 24. This provision has
extended coverage to millions of young adults who might otherwise have been uninsured.
Rationale 2:
This statement is incorrect. The ACA prohibits insurance companies from denying coverage
to children under the age of 19 due to preexisting conditions. This provision ensures that
children with preexisting conditions have access to health insurance coverage.
Rationale 3:
This statement is correct. One of the actions enacted upon the president's signature of the
Affordable Care Act is that new health insurance plans must offer certain preventive services
and screenings without charging a copayment, coinsurance, or deductible. This provision
aims to encourage preventive care and early detection of health issues by removing financial
barriers for patients.
Rationale 4:
This statement is incorrect. The Affordable Care Act prohibits the imposition of lifetime
limits on essential health benefits. Before the ACA, many insurance plans imposed lifetime
limits on benefits, meaning that once a certain dollar amount was reached, the insurance
would no longer cover any additional expenses. The ACA's prohibition on lifetime limits
ensures that individuals with serious medical conditions do not face the risk of exhausting
their benefits entirely.
Question 23
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 (n.d., p.
1) that includes which of the following measures?
1. Compliance with health and safety laws and regulations
2. Compliance with fraud complaints
3. Compliance with environmental laws and regulations
4. Compliance with human resources laws and regulations
5. Compliance with HIPAA laws and regulations
Correct Answer: 1,3,4,5
Rationale 1:
Compliance with health and safety laws and regulations is essential for maintaining a safe
environment for patients, staff, and visitors in medical facilities. This includes adherence to
standards set forth by regulatory bodies such as OSHA (Occupational Safety and Health
Administration) and ensuring compliance with requirements related to infection control,
emergency preparedness, and workplace safety.
Rationale 2:
Compliance with fraud complaints is important for healthcare providers to avoid legal
repercussions and maintain integrity in billing practices. However, it is not specifically
mentioned in the context of the measures outlined by the Fox Group's website for a medical
compliance program.
Rationale 3:
Compliance with environmental laws and regulations ensures that medical facilities minimize
their impact on the environment and comply with regulations related to waste disposal,
hazardous materials management, and other environmental considerations. This aspect is
crucial for maintaining sustainability and meeting legal requirements.
Rationale 4:
Compliance with human resources laws and regulations is necessary to ensure fair and
equitable treatment of employees, adherence to labor laws, and compliance with regulations
related to hiring, termination, wages, benefits, and workplace discrimination. Establishing
and maintaining compliance with these laws helps protect both employees' rights and the
organization's legal standing.
Rationale 5:
Compliance with HIPAA (Health Insurance Portability and Accountability Act) laws and
regulations is vital for protecting patients' privacy and ensuring the security of their health
information. Healthcare providers must implement safeguards to protect patient
confidentiality, maintain the integrity of health records, and comply with HIPAA's privacy
and security rules to avoid legal penalties and maintain trust with patients.
Question 24
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?
1. Provided loans to physicians to purchase technology
2. Offered physicians stipends if they use the equipment correctly
3. Has given financial aid to larger practices to purchase equipment
4. Has given physicians the equipment to convert to electronic health records
Correct Answer: 1
Rationale 1:
The government has provided loans to physicians, particularly through programs like the
Medicare and Medicaid EHR Incentive Programs (also known as Meaningful Use), to assist
them in purchasing and implementing electronic health record (EHR) systems. These
incentive programs offer financial incentives, in the form of payments, to eligible healthcare
professionals and practices that demonstrate meaningful use of certified EHR technology.
These payments help offset the costs associated with adopting and maintaining EHR systems,
making the transition more feasible for small primary care practices.
Rationale 2:
While the government does offer incentives to encourage meaningful use of EHR systems,
these incentives are typically in the form of payments rather than stipends. Physicians and
practices receive payments based on their successful utilization of EHR technology to
improve patient care and healthcare delivery, rather than receiving stipends for simply using
the equipment correctly.
Rationale 3:
While larger practices may also receive financial assistance or incentives for adopting EHR
systems, the primary focus of government programs like Meaningful Use has been to support
smaller practices, which often face greater financial barriers to EHR adoption. However, the
government's efforts to support EHR adoption are not limited to larger practices.
Rationale 4:
The government generally does not provide physicians with the equipment itself to convert to
electronic health records. Instead, it provides financial assistance in the form of loans,
incentives, or payments to help offset the costs of purchasing and implementing EHR
systems. Physicians are responsible for selecting and acquiring their own EHR technology
based on their practice needs and preferences.
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?
1. Nursing professionals will spend more time at the computer and less time at the bedside.
2. There will be surge in applications for certified nursing assistant positions.
3. There will be a decreased need for point-of-care nurses.
4. There will be an increased need for nurse informatics specialists.
Correct Answer: 4
Rationale 1:
While the implementation of electronic health records (EHRs) and other mandated
technology use may result in nursing professionals spending more time using computers, it
does not necessarily mean they will spend less time at the bedside. The impact on bedside
nursing time can vary depending on factors such as workflow efficiency, support staff
availability, and the design of the technology implementation.
Rationale 2:
The Affordable Care Act's impact on nursing is not directly linked to a surge in applications
for certified nursing assistant (CNA) positions. The ACA focuses more on healthcare reform,
insurance coverage, and delivery system improvements rather than specific workforce
recruitment trends.
Rationale 3:
The ACA's impact on nursing is unlikely to result in a decreased need for point-of-care
nurses. Point-of-care nurses, who provide direct patient care at the bedside or in other clinical
settings, remain essential for delivering high-quality patient care and are not typically
affected by changes in technology use mandated by the ACA.
Rationale 4:
The Affordable Care Act has led to an increased emphasis on healthcare technology and the
use of electronic health records (EHRs) to improve patient care coordination, quality, and
efficiency. As a result, there is a growing demand for nurse informatics specialists who have
expertise in leveraging health information technology to support nursing practice, enhance
workflow processes, and optimize the use of EHR systems. Therefore, there is an increased
need for nurse informatics specialists due to the mandates of the ACA.
Question 26
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?
1. The informatics nurse has the responsibility of maintaining the compliance procedures of
the health care setting.
2. The informatics nurse has the responsibility of analyzing the coding system.
3. The informatics nurse has the responsibility to serve as the liaison between physician and
patient and physician and agency.
4. The informatics nurse has the responsibility of creating meaningful use policies.
Correct Answer: 3
Rationale 1:
While the informatics nurse may be involved in aspects of compliance related to health
information technology and electronic health record (EHR) systems, their primary
responsibility is not maintaining compliance procedures for the entire healthcare setting.
Compliance procedures typically involve a broader range of regulatory and organizational
requirements that may be overseen by compliance officers or administrators.
Rationale 2:
Analyzing the coding system is not typically a primary responsibility of the informatics
nurse. While informatics nurses may work with coding systems within the context of
electronic health records (EHRs) and health information systems, their role is more focused
on optimizing the use of technology to support patient care, clinical workflow, and data
management rather than directly analyzing coding systems.
Rationale 3:
The statement is true. The informatics nurse often serves as a liaison between healthcare
providers (including physicians) and patients, as well as between different departments or
agencies within the healthcare organization. They facilitate communication, provide
education and support, and ensure that technology systems meet the needs of both clinicians
and patients.
Rationale 4:
While informatics nurses may be involved in the development and implementation of
meaningful use policies related to electronic health records (EHRs) and health information
technology, creating such policies is not their sole responsibility. Meaningful use policies
may be developed collaboratively by various stakeholders, including informatics specialists,
administrators, clinicians, and regulatory agencies.
Question 27
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?
1. Guide IT technicians
2. Work closely with physicians
3. Spearhead policy reform
4. Develop evidence based practice models
5. Participate in research initiatives
Correct Answer: 1,2,3,4,5
Rationale 1:
Nurses with informatics experience and education may be placed in leadership roles to guide
IT technicians in the implementation, maintenance, and optimization of healthcare
technology systems. Their understanding of both nursing practice and technology enables
them to effectively communicate with IT personnel and ensure that technology solutions meet
the needs of nurses and other healthcare providers.
Rationale 2:
Nurses with informatics expertise often work closely with physicians and other healthcare
professionals to integrate technology into clinical workflows, improve patient care processes,
and enhance communication and collaboration among members of the healthcare team. Their
role in leadership positions involves facilitating interdisciplinary teamwork and ensuring that
technology solutions align with clinical practice goals.
Rationale 3:
Nurses with informatics knowledge may spearhead policy reform initiatives related to
healthcare technology adoption, implementation, and utilization. They advocate for policies
that promote the effective use of technology to improve patient outcomes, enhance care
delivery, and support evidence-based practice. Their leadership in policy development helps
shape the regulatory and organizational landscape of healthcare informatics.
Rationale 4:
Nurses with informatics expertise play a key role in developing evidence-based practice
models that leverage healthcare technology and data analytics to inform clinical decisionmaking, improve patient outcomes, and enhance the quality and safety of care. Their
leadership in evidence-based practice initiatives involves synthesizing research findings,
integrating best practices into clinical workflows, and evaluating the impact of technology
interventions on patient care.
Rationale 5:
Nurses with informatics experience and education are well-positioned to participate in
research initiatives that explore the use of technology in healthcare settings. Their
understanding of nursing practice, technology systems, and data analysis enables them to
contribute valuable insights to research projects focused on areas such as health informatics,
nursing informatics, telehealth, and health information exchange. Their leadership in research
initiatives helps advance knowledge and innovation in the field of healthcare informatics.
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?
1. A need for increased supplies
2. The need to hire more staff
3. The need to monitor patient outcomes
4. The need to hire additional health information technology (HIT) coordinators
Correct Answer: 3
Rationale 1:
The expansion of healthcare coverage under the Patient Protection and Affordable Care Act
(PPACA) may indeed lead to an increased need for supplies to accommodate the larger
number of patients accessing healthcare services. As more individuals gain access to
healthcare, there may be higher demand for medical supplies, medications, and equipment to
support patient care.
Rationale 2:
The increase in the number of people with access to healthcare as a result of the PPACA may
necessitate the hiring of more staff to meet the growing demand for healthcare services. This
could include hiring additional physicians, nurses, allied health professionals, administrative
staff, and support personnel to provide care and support patient needs.
Rationale 3:
Monitoring patient outcomes is not a direct financial impact of the PPACA. While the Act
aims to improve access to affordable healthcare and enhance the quality of care, the financial
implications of monitoring patient outcomes are more related to the investments in healthcare
infrastructure, technology, and personnel needed to support quality improvement initiatives,
rather than being a direct financial consequence of the Act itself.
Rationale 4:
The implementation of health information technology (HIT) is a significant component of the
PPACA, aimed at improving healthcare delivery, coordination, and efficiency. Hiring
additional health information technology (HIT) coordinators or specialists may be necessary
to facilitate the adoption, implementation, and optimization of electronic health records
(EHRs) and other HIT systems required to support the goals of the Act. Therefore, the need to
hire additional HIT coordinators is a financial impact of the PPACA.
Test Bank for Handbook of Informatics for Nurses and Healthcare Professionals
Toni Lee Hebda, Patricia Czar, Theresa Calderone
9780132574952, 9780132959544, 9780134711010, 9780131512627, 9780130311023, 9780805373264, 9780135205433, 9780135043943
