NUR 425 Test 3 Questions with 100% Correct
Answers
3 Primary Sources that Pay for Healthcare
Government (Medicare & Medicaid), private health insurance (through your job), and out-of-
pocket (includes deductibles, copayments, and anything paid by the individual)
Medicare Part A
Federal program that is the insurance plan for hospital, hospice, home health, and skilled
nursing care paid through with social security taxes. Nursing home care is NOT covered.
Medicaid
State level programs funded by state and federal. Pays for services for the blind, disabled,
medically indigent, children with disabilities and covers a lot.
Cost-Based System
Consists of the cost of providing a service plus an additional cost for profit. Third party
payers costs decided by surveying a certain area, and payment is selected after the service is
provided.
Contractual Allowance
Given when reimbursed amount is less than the full charge of service in a cost-based system
because it is similar to a "discount" for the third party payer.
Prospective Payment System
Third-party payer decides what and how much will be paid for a service. If the cost of care is
higher than the payment, the provider absorbs the loss. Profit is made when the cost of care is
lower.
, Diagnosis Related Groups
Basis of payment in the Prospective Payment System which groups people based on their
diagnosis on their average hospital stay, lab costs, surgeries, therapies, etc. Does not
accurately reflect patient intensity or acuity. PPS with DRG caused increased patient acuity
and decreased length of stay in hospitals
Value Based Purchasing/Pay-for-Performance
Reimbursed based on performance and outcomes versus rather than considering the cost of
providing certain care. Based on quality outcomes, staff responsiveness, cleanliness,
quietness of hospital environment
Capitation
Form of Prospective Based Payment. It is a Decided amount of what will be paid per patient
per days, not based on the procedure. There is a profit when the stay is shorter for patients.
Nurse's Role in Capitation
Nurse must strive to do more in a visit to prevent return visits and complications as they are
working on only a set amount of days that is being paid for. They need to complete care
under the set amount of paid days for the company to make a profit
Nurse's Role with Case Management
Knowledge of patient goals and anticipated discharge date. Appropriate and timely
interventions when the patient isn't progressing as expected. Ongoing patient and family
education. Identifying barriers to discharge.
Operating Budget Defined
Answers
3 Primary Sources that Pay for Healthcare
Government (Medicare & Medicaid), private health insurance (through your job), and out-of-
pocket (includes deductibles, copayments, and anything paid by the individual)
Medicare Part A
Federal program that is the insurance plan for hospital, hospice, home health, and skilled
nursing care paid through with social security taxes. Nursing home care is NOT covered.
Medicaid
State level programs funded by state and federal. Pays for services for the blind, disabled,
medically indigent, children with disabilities and covers a lot.
Cost-Based System
Consists of the cost of providing a service plus an additional cost for profit. Third party
payers costs decided by surveying a certain area, and payment is selected after the service is
provided.
Contractual Allowance
Given when reimbursed amount is less than the full charge of service in a cost-based system
because it is similar to a "discount" for the third party payer.
Prospective Payment System
Third-party payer decides what and how much will be paid for a service. If the cost of care is
higher than the payment, the provider absorbs the loss. Profit is made when the cost of care is
lower.
, Diagnosis Related Groups
Basis of payment in the Prospective Payment System which groups people based on their
diagnosis on their average hospital stay, lab costs, surgeries, therapies, etc. Does not
accurately reflect patient intensity or acuity. PPS with DRG caused increased patient acuity
and decreased length of stay in hospitals
Value Based Purchasing/Pay-for-Performance
Reimbursed based on performance and outcomes versus rather than considering the cost of
providing certain care. Based on quality outcomes, staff responsiveness, cleanliness,
quietness of hospital environment
Capitation
Form of Prospective Based Payment. It is a Decided amount of what will be paid per patient
per days, not based on the procedure. There is a profit when the stay is shorter for patients.
Nurse's Role in Capitation
Nurse must strive to do more in a visit to prevent return visits and complications as they are
working on only a set amount of days that is being paid for. They need to complete care
under the set amount of paid days for the company to make a profit
Nurse's Role with Case Management
Knowledge of patient goals and anticipated discharge date. Appropriate and timely
interventions when the patient isn't progressing as expected. Ongoing patient and family
education. Identifying barriers to discharge.
Operating Budget Defined
