Issues and Trends
Reimbursement Issues
Current Procedural Terminology (Cpt) Coding System.
The adult-gerontology acute care nurse practitioner’s (AGACNP) responsibilities include providing excellent patient care, coding patient services, billing the services and executing reimbursements for treatments (“Current procedural terminology®,” 2020). There is a need to educate AGACNP on essential legal elements because legal issues about the negligence of patients may arise. It is also their responsibility to stay on top of issues and educate themselves on possible legal issues that may arise from malpractice charges.
In 1966, the current procedural terminology (CPT) coding system was published which describes procedures related to surgery and other medical and radiology services (“Current procedural terminology®,” 2020). Since the time, the CPT coding system has undergone many amendments. The CPT coding system was officially published in 2000 as a national system for reporting physician and other healthcare professional’s procedures (Hameed, 2017). This system is used by AGACNP to record procedures from which the healthcare facility can charge the patients. However, if the AGACNP receives a salary for their services to the hospital, they cannot claim any further reimbursement (Hameed, 2017).
Medicare Coverage.
According to the Medicare coverage reimbursement, the AGACNP is required to have first obtained billing privileges which are done by submitting the required information (“Medicare and the Affordable Care Act,” 2018). They are also required to have obtained a National Provider Identifier (NPI) which can be used to bill the Medicare program. Both the Physician and AGACNP can bill the Medicare program if they attend to a patient face to face. According to the Medicare Physician Fee Schedule, AGACNP receives a reimbursement that is 15% less than what the Physician gets (“Medicare and the Affordable Care Act,” 2018).
Medicaid.
The reimbursement under Medicaid is controlled by the state and therefore it differs from state to state. For example, in Florida, the AGACNP cannot practice without being accompanied by a physician (Smith & Moore, 2017). They also receive 20% less than what the physician receives for work done in that state. In Florida, if during surgery, the AGACNP is a first assistant to the physician, then their rate is fixed to 12.8% of what the physician is paid (Smith & Moore, 2017).
Fee for Service Indemnity Plans.
Fee for service indemnity plans is the health insurance plans where the patient decides the best healthcare facility of their choice. However, these plans turn out to be more expensive to the consumer than other products in the market as they only pay for services that are administered (“ACA round-up: Market stabilization, fixed-indemnity plans, cost-sharing reductions, and penalty updates,” 2017). However, the health care provider must bill the insurance company for the services rendered to the consumer. Most often, the insurance company pays 80% of the hospital bill while the patient is required to clear the rest of the bill. With the indemnity plan, the AGACNP is entitled to 85% of the physician fee (“ACA round-up: Market stabilization, fixed-indemnity plans, cost-sharing reductions, and penalty updates,” 2017).
Legal theories of Adult-Gerontology ACNP
Professional (Medical) Negligence.
Professional negligence is the failure of a licensed medical practitioner to use due care under given circumstances as would be expected from a reasonable and prudent person. The term malpractice is the common legal term for medical negligence. Malpractice claims against AGACNP have been on the rise over the years. AGACNP must ensure that they have competent skills in their work (Bell, 2016). Medical liability insurance is required countrywide as AGACNP are held legally liable for actions while providing healthcare services.
Essential Elements.
Duty.
An AGACNP has the duty to provide expertise in acute care where they are required to handle complex patient situations, including establishing an immediate health condition, ordering and interpreting diagnostic tests, and coming up with a treatment plan to stabilize patients and maximize the overall senior health. In some states, they are required to write prescriptions.
Legally, the AGACNP is required to exercise the duty of care in a reasonable capacity where a similar practitioner in the same field would under comparable circumstances (Watson, 2014). Otherwise, it would be termed as medical negligence which is unethical or unfit conduct involving lack of skill by the practitioner (Watson, 2014). Negligence results in legal liability for actions and omissions against the AGACNP.
Causation.
Causation refers to the injury’s cause and impact (Korn & Matthews, 2012). In most cases, causation is usually hard to prove since it depends on the explanation of the what-if scenario (Korn & Matthews, 2012). It can result in many ‘what-ifs’ situations regarding hospitalization and treatment. Causation can also be expounded as a cause and impact matter, for instance, if the sick person had not fractured his leg, he or she would not have contracted a DVT. Owing to this reason, it is important to stay within the scope of practice and fully attend to the patient to the best of your ability as a practitioner.
Failure to Obtain Informed Consent or Refusal.
Before administering any procedures on the patient, the AGACNP must obtain well-informed consent from the patient. Here, the practitioner is required to disclose all necessary information about the case. He or she must relay information about all the accruing advantages of the treatment, probable risks of harm, and the likelihood and extent of the likely harm as well as any alternative treatments available (Horner et al., 2016).
Thereafter, the victim can opt to reject the treatment and select an alternative treatment based on their wishes (Horner et al., 2016). Failure to disclose all information to obtain informed consent may result in judicial litigations since the duty of disclosure is required by both the federal and state constitution (Horner et al., 2016).
According to Welie and Have (2014), treating patients against the sick person’s wishes constitutes a battery. Legally, patients must always be given informed consent. In the event the victim ends up unconscious in an emergency room, they are assumed to have consent. In case the practitioner knowingly provides treatment against the patient’s will, he or she violates non-maleficence and it could end up in a legal battle ((Welie & Have, 2014).
Withholding/withdrawal of treatment.
In some cases, withholding or withdrawing treatment is a huge dilemma for an AGACNP. According to Welie and Have (2014), withholding care is the act of halting medical treatments that have already been started, for example, removing a victim from the ventilator. This action is hard for the AGACNP and the family since they must physically eradicate the life-sustaining treatment.
On the other hand, dealing with withdrawal may be legally easier in comparison to withholding treatment. This is because, an argument can hold that even if unsuccessful, at least there was an initiation of the treatment and a fighting option was given to the victim (Welie & Have, 2014). It is therefore imperative to seek the patient’s informed consent or alternative power of attorney before administering either withholding or withdrawal of the treatment (Welie & Have, 2014).
Legal Considerations for Practice.
Failure to Adequately Assess/Obtain Adequate History.
According to Bickley et al (2020), obtaining sufficient history of the health of the patient is essential for establishing any underlying conditions the person may have but might have failed to mention. In some cases, patients may forget to state something in their family’s history, for instance, a history of a certain type of cancer that could constitute additional investigation by the AGACNP. The AGACNP could initiate further testing.
It is, therefore, the duty of the AGACNP to ensure that he or she receives enough details on the family history, past medical diagnosis, social history to ensure that he or she makes informed decisions concerning diagnostic treatment as well as plans for treatment (Bickley et al., 2020).
Failure to Diagnose/Misdiagnosis.
Failing to diagnose or misdiagnose the patient can prove costly to the AGACNP as it is considered a form of negligence (Capozzola et al., 2017). If the court establishes that another AGACNP at a similar facility under similar conditions would not have failed the diagnosis, the practitioner may face both legal charges and financial implications (Capozzola et al., 2017).
The main concern for the misdiagnosis is usually the lack of obtaining sufficient diagnostic testing including ECH, CT scans, ECG among others (Capozzola et al., 2017). It is, therefore, crucial for the practitioner to carefully chose appropriate diagnostic tests to eliminate all differential diagnoses and where unsure, seek consultation from other qualified practitioners.
Failure to Properly Treat or Intervene.
There is an expectation that an AGACNP will apply a high standard of care to administer treatment to patients. He or she must take all appropriate steps to ensure that the treatment is appropriate (Capozzola et al., 2017). The AGACNP must receive the full history and evaluate all the symptoms of the patient before initiating any form of treatment.
In addition, there is a need to have proper documentation of the evaluation, plan for treatment, and history since without proper documentation, there is no proof of proper treatment administration. Failing to give proper treatment as well as intervene in specific situations may result in legal liability and financial consequences against the AGACNP.
Failure to Obtain A Timely Consult or Referral.
According to Goodwin et al (2015), failing to acquire timely consultation or referral subjects the patient at risk of avoidable pain, damage, or suffering. It is, therefore, crucial for the practitioner to be aware of when to seek assistance in the form of a referral to a specialist service (Goodwin et al., 2015). Failing to refer or seek a consult may result in an accusation of negligence in cases of medical issues arising and they are not specialized to handle the situation.
Conclusion
In a nutshell, an AGACNP must understand that he or she has a duty and responsibility to the patient. Consequently, he or she must take up the responsibility to comprehend the reimbursement matters, all elements of professional negligence, and the practice’s legal considerations. In doing so, they will avoid any legal and financial consequences.
References
ACA round-up: Market stabilization, fixed-indemnity plans, cost-sharing reductions, and penalty updates. (2017). Forefront Group. https://doi.org/10.1377/forefront.20170208.058674
Bell, L. (2016). Acute & critical care nurse practitioner: Cases in diagnostic reasoning. Critical Care Nurse, 36(3), 73-73. https://doi.org/10.4037/ccn2016450
Bickley, L., Szilagyi, P., Hoffman, R., & Soriano, R. (2020). Bates’ guide to physical examination and history taking (13th ed.).
Capozzola, D., Barnes, S., Kures, M., Martin, S., & Olivier, M. (2017). Did a Patient Exhibit Abnormal Test Results Post-discharge?. Reliasmedia.com. https://www.reliasmedia.com/articles/138044-did-a-patient-exhibit-abnormal-test-results-post-discharge
Current procedural terminology®. (2020). Pediatric Coding Basics: An Introduction to Medical Coding, 33-52. https://doi.org/10.1542/9781610024051-ch03
Hameed, H. (2017). Current procedural terminology. Treatment of Chronic Pain Conditions, 333-334. https://doi.org/10.1007/978-1-4939-6976-0_96
Horner, J., Modayil, M., Chapman, L., & Dinh, A. (2016). Consent, Refusal, and Waivers in Patient-Centered Dysphagia Care: Using Law, Ethics, and Evidence to Guide Clinical Practice. American Journal of Speech-Language Pathology, 25(4), 453-469. https://doi.org/10.1044/2016_ajslp-15-0041
Medicare and the Affordable Care Act. (2018). The Affordable Care Act, 143-157. https://doi.org/10.4324/9780203722572-15
Smith, D. G., & Moore, J. D. (2017). Legislating Medicaid. Medicaid Politics and Policy, 19-46. https://doi.org/10.4324/9781351295802-2
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