Competition in Health Care

NR 511 Weekly Discussions
A 56-year-old Caucasian female presents to the office today with complaints of fatigue. Upon further questioning you discover the following subjective information regarding the chief complaint.
History of Present Illness
Onset \”about 2-3 months\”
Location Generalized
Duration Constant
Characteristics Progressively worsening since onset, feels tired all of the time, sleeps 8hrs per night but does not feel well rested. \”No energy to do anything I normally can do\”
Aggravating factors Exertion
Relieving factors None identified
Treatments None
ORDER A PLAGIARISM-FREE PAPER NOW
Severity Denies pain; missed 1 day of work 2 weeks ago because \”couldn\’t get out of bed\”
Review of Systems (ROS)
Constitutional Denies fever, chills, or recent illnesses. +5lb. weight gain since last visit 6 months ago.
Eyes No visual changes or diploplia
ENT Denies ear pain, coryza, rhinorrhea, or ST. Had tonsillectomy as child Denies snoring or history of sleep apnea.
Neck Denies lymph node tenderness or swelling
Chest Denies cough, SOB, DOE or wheezing
Heart Denies chest pain
Abdomen Denies N/V/D. + Constipation
Endocrine Denies polyuria, polydipsia. + cold intolerance. Menopause status x 5 yrs.
Skin No changes in skin, hair or nails
Psych Reports worsening of depressive symptoms but thinks it is because she is so \”unproductive\” lately and tired all of the time. -Suicidal or homicidal thoughts. Sleeping 8-9hrs per night (no changes), but not feeling rested.
Musculoskeletal Generalized weakness and intermittent muscles cramping in calves
History – NR 511 Weekly Discussions
Medications Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg + Vit D3 400IU.
PMH HTN, Depression, Postmenopausal status
PSH Tonsillectomy
Allergies Iodine dyes
Social Married; Works full time as office manager of an internal medicine office; 2 kids (grown)
Habits Denies cigarettes or drug use. +Occasional glass of wine (1-2 per month).
FH Maternal GM & GF deceased with CHF, T2DM and HTN;
Mother alive (age 82) +HTN, +Hyperlipidemia, +T2DM;
Father alive (age 84) +HTN, +Hyperlipidemia, +T2DM, +ASHD (s/p CABG 2 years ago). Also had +CVA at time of CABG (work-up revealed +DVT and +PFO; remains anticoagulated);
Oldest child (26) with seasonal allergies
Youngest child (24) with Bipolar depression and ADHD, and anxiety
Physical exam reveals the following:
Physical Exam – NR 511 Weekly Discussions
Constitutional Middle aged Caucasian female alert, oriented and cooperative
VS Temp-98.2, P-74, R-16, BP 146/95, Height: 5\’7\”, Weight: 180 pounds
Head Normocephalic, atraumatic
Eyes PERRLA
Ears Tympanic membranes gray and intact with light reflex noted.
Nose Nares patent. Nasal turbinates without swelling. Nasal drainage is clear.
Throat Oropharynx moist, no lesions or exudate. Surgically removed tonsils bilaterally. Teeth in good repair, no cavities.
Neck Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
Cardiopulmonary Heart S1 and s2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. No pedal edema
Abdomen Soft, non-tender. BS active
Skin Skin overall dry, hair coarse and thick, nails without ridging, pitting or discoloration
Psych Mood pleasant and appropriate.
Musculoskeletal Strength full throughout
Neuro DTRs 2+ at biceps, 1+ at knees and ankles
1. Briefly and concisely summarize the H&P findings as if you were presenting it to your preceptor using the pertinent facts from the case. Use shorthand where possible and approved medical abbreviations. Avoid redundancy and irrelevant information. NR 511 Weekly Discussions.
2. Provide a differential diagnosis (minimum of 3) which might explain the patient\’s chief complaint along with a brief statement of pathophysiology for each.
3. Analyze the differential by using the pertinent findings from the history and physical to argue for or against a diagnosis.
4. Rank the differential in order of most likely to least likely. NR 511 Weekly Discussions
5. Identify any additional tests and/or procedures that you feel is necessary or needed to help you narrow your differential. All testing decisions must be supported with an evidence-based medicine (EBM) argument as to why it is necessary or pertinent in this case. If no testing is indicated or needed, you must also support this decision with EBM.
NR 511 Weekly Discussions
Week 6: Discussion Part Two
.
CBC with differential
WBC 8.6 x10E3/uL
RBC 4.44 x 10E6/uL
Hemoglobin 14.0 g/dL
Hematocrit 41.2%
MCV 93fL
MCH 31.5 pg
MCHC 34.0 g/dL
RDW 13%
Platelet 241 x 10E3/uL
Neutrophils % 67%
Lymphocytes % 22%
Monocytes % 8%
Eosinophils % 3%
Basophils % 0%
Absolute Neutrophils 5.7 x 10E3/uL
Absolute Lymphocytes 1.9 x 10E3/uL
Absolute Monocytes 0.7 x 10E3/uL
Eosinophils Absolute 0.3 x 10E3/uL
Basophile Absolute 0.0 x 10E3/uL
Immature Grans % 0%
Absolute Immature Grans 0.0 x 10E3/uL
TSH with Reflex to FT4
TSH 6.770 uIU/mL
FT4 0.62 ng/dL
PHQ-9 Depression Score=10 (previous was 5 at last visit 6 months ago)
1. What is your primary diagnosis for this patient as the cause for the CC of fatigue? (support your decision for your diagnosis with pertinent positives and negatives from the case)
2. Identify the corresponding ICD-10 code. NR 511 Weekly Discussions.
3. Provide a treatment plan for this patient\’s primary diagnosis which includes:
o Medication*
o Any additional testing necessary for this particular diagnosis*
o Patient education*
o Referral
4. Provide an active problem list for this patient based on the information given in the case.
5. Are there any changes that you would make to the patient\’s overall plan at this time? Must provide an evidence-based medicine (EBM) argument to support any treatments or testing decisions. NR 511 Weekly Discussions.
6. Provide an appropriate follow-up plan (include any additional testing that you feel is necessary and include an EBM argument). NR 511 Weekly Discussions.
*If part of the plan does not warrant an action, you must explain why. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST be supported with an EBM argument. Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office.
Search entries or author . NR 511 Weekly Discussions

Nursing Questions and Answers
Question 1
When a provider receives a fixed amount to provide only the care that an individual needs from the provider, this is known as a _____________ payment.
capitation
fixed
premium
sub-capitation
4 points Save Answer
Question 2
The healthcare industry is heavily regulated by ____ and ____ legislation.
city; local
state; city
county; state
federal; state
4 points Save Answer
Question 3
When a patient signs a release of medical information at a physician’s office, that release is generally considered to be valid
for six months
for a single visit to the physician
for one year from the date entered on the form
until the patient changes insurance companies
4 points Save Answer
Question 4
When the provider is required to receive as payment in full whatever amount the insurance reimburses for services, the provider is agreeing to
accept assignment
assignment of benefits
authorize services
coordination of benefits
4 points Save Answer
Question 5
Which document is used to guarantee the patient’s financial and medical record?
encounter form
patient insurance form
patient ledger
patient registration form
4 points Save Answer
Question 6
The person responsible for paying the charges for services rendered by the provider is the
beneficiary
guarantor
guardian
subscriber
4 points Save Answer
Question 7
Which federal legislation was enacted in1995 to restrict the referral of patients to organizations in which providers have a financial interest?
Federal Anti-Kickback Law
Hill-Burton Act
HIPAA
Stark II laws
4 points Save Answer
Question 8
The recognized difference between fraud and abuse is the
cost
intent
payer
timing
4 points Save Answer
Question 9
The specified amount of annual out-of-pocket expenses for covered health care services that the insured must pay annually for health care is called the
coinsurance
copayment
deductible
premium
4 points Save Answer
Question 10
Which three components constitute the RBRVS payment system?
fee schedule, practice expense, and malpractice expense
physician work, practice expense, and geographical location
physician work, practice expense, and malpractice insurance espense
practice expense, malpractice insurance expense, and liability insurance expense
4 points Save Answer
Question 11
Mandates are
directives
laws
regulations
standards
4 points Save Answer
Question 12
Which type of HMO offers subscribers health care services by physicians who remain in their individual office setting?
closed panel
independent practice association
network model
staff model
4 points Save Answer
Question 13
HIPAA requires payers to implement rules called electronic __________, which result in a uniform language for electronic data interchange.
data interchanges
health records
medical records
transaction standards
4 points Save Answer
Question 14
The ambulatory payment classification prospective payment system is used to reimburse claims for what services?
inpatient
nursing facility
outpatient
rehabilitation
4 points Save Answer
Question 15
Breach of confidentiality can result from
discussing patient health care information with unauthorized sources
discussing the patient’s case in the business office
sending medical information to non-health care entities with the patient’s consent
sending patient health care information to the patient’s insurance company
4 points Save Answer
Question 16
When a patient elects to receive care from a non-PAR, the patient will accrue _____.
higher copays
higher out-of-pocket expenses
lower premiums
lower copays
4 points Save Answer
Question 17
When a number of people are grouped for insurance purposes, this is known as a(n)
adverse selection
insurance pool
member group
risk pool
4 points Save Answer
Question 18
Because the diagnosis and procedure codes reported affect the DRG selected (and resultant payment), some hospitals engaged in a practice called __________, which is the assignment of an ICD-10-CM diagnosis code that does not match patient record documentation, for the purpose of illegally increasing reimbursement.
downcoding
jamming
unbundling
upcoding
4 points Save Answer
Question 19
The problem-oriented record (POR) is a systematic method of documentation that consists of
a database.
progress notes.
an initial plan.
all of the above.
4 points Save Answer
Question 20
Which of the following is an example of fraud?
billing noncovered services as covered services
falsifying certificates of medical necessity plans of treatment
reporting duplicative charges on an insurance claim
submitting claims for services not medically necessary
4 points Save Answer
Question 21
Care rendered to a patient that was not properly approved (e.g., preapproved) by the insurance company is known as
medical necessity
noncovered benefits
unapproved services
unauthorized services
4 points Save Answer
Question 22
A risk contract is defined as an arrangement among health care providers
stating that the HMO can provide services to Medicare beneficiaries only
that allows higher payments to the HMO if they treat Medicare beneficiaries
to make available capitated health care services to Medicare beneficiaries
to offer fee-for-service health care services to Medicare beneficiaries
4 points Save Answer
Question 23
Which of the following is an example of abuse?
billing noncovered services/procedures as covered services/procedures
falsifying health care certificates of medical necessity plans of treatment
misrepresenting ICD-10-CM and CPT/HCPCS codes to justify payment
submitting claims for services and procedures knowingly not provided
4 points Save Answer
Question 24
Preventive services
may result in the early detection of health problems.
are required by most insurance companies.
allow treatment options that are less dramatic and less expensive.
both a and c.
4 points Save Answer
Question 25
Drew Baker is referred to a health care provider by an employer for treatment of a fracture that occurred during a fall at work. The physician billed Medicare and did not indicate on the claim that the injury was work related. Medicare benefits were paid to the provider for services rendered. This resulted in Medicare contacting the provider, who is liable for the __________ because of the provider’s failure to disclose that the injury was work-related.
adjudication
mediation
overpayment
unbundling