Health Care Financial Management for Nurse Managers: Applications in Hospitals, Long-Term Care, Home Care, and Ambulatory Care

by Dunham-Taylor, Janne; Pinczuk, Joseph Z.

• ISBN13: 9780763734756
• ISBN10: 0763734756
• Format: Paperback
• Copyright: 2005-08-12
• Publisher: Jones & Bartlett Learning

Summary

This text applies financial concepts to various health care settings, details how reimbursement varies between these settings, and teaches nurse managers how to effectively manage financial data specific to each setting. The chapters on long-term care explain the Resident Assessment Instrument (RAI), including the Minimum Data Set (MDS), as well as how to best manage long term care resources. The home care chapters explore how home care is financed, and how to administrate financial resources in a home health agency. In the chapters on ambulatory care, the text discusses the ins and outs of reimbursement in primary care.

Table of Contents

Preface	xvii
Contributors	xix
Part I Hospital Issues	1	(178)
Overview of Hospital-Based Care	3	(84)
Jane K. Walker
Introduction	3	(1)
Classification of Hospitals	4	(11)
General versus Specialty	4	(1)
Teaching versus Community	4	(3)
Ownership---For-Profit, Not-for-Profit, Government	7	(1)
Critical Access Hospitals	8	(5)
The Changing Health Care Environment	13	(2)
Reimbursement Issues	15	(9)
Outpatient Reimbursement	17	(1)
Inpatient Observation Patients	18	(1)
Observation Status Fraud	19	(1)
Staffing Implications of Observation Patients	20	(1)
Patient Classification Systems	20	(4)
What Things Impact the Bottom Line for Hospitals?	24	(6)
Different Strokes for Different Folks	24	(2)
Payor Mix	26	(2)
Impact of Labor Costs on Budgeting	28	(1)
Outsourcing Operational Management Personnel/Improvements	29	(1)
Supply Issues	30	(1)
Physician Issues	30	(8)
Trending Toward a Shortage?	30	(1)
Physician Alliances and Contracts	31	(1)
Other Physician Practice Patterns	31	(3)
Gain Sharing	34	(1)
Medical Directorships	35	(1)
I Said Stark, not Stork	36	(1)
Technological Advances in Physician Practice	37	(1)
Nursing Issues	38	(17)
Career Choices	38	(1)
Some Stats and Contributing Factors	38	(1)
Impact on Patient Care	39	(1)
Magnet Hospital Program	40	(1)
Working with the Number Crunchers	40	(1)
Case Management	41	(2)
Case Management Types	43	(1)
Critical Pathways	44	(1)
Variances in Critical Pathways	45	(5)
Outcomes Research and Management	50	(1)
Utilization Management---Precertification, Utilization Review, Discharge Planning, and Retrospective Review	51	(4)
Compliance, Quality, Evaluation, Accreditation, and Risk Management Issues	55	(25)
Compliance and Risk Management	55	(1)
Performance Evaluation and Improvement Measures	56	(1)
What Is Benchmarking?	57	(1)
Benchmarking in Hospital-Based Health Care	58	(2)
What Is the Balanced Scorecard?	60	(2)
The Balanced Scorecard in Hospital-Based Health Care	62	(2)
Other Evaluation Measures---Quality (TQM, CQI, QI, and QA)	64	(8)
Accreditation	72	(4)
HIP What?	76	(3)
HIPAA Compliance	79	(1)
Conclusion	80	(1)
References	80	(7)
Using Inpatient Tools to Predict Cost and Measure Performance	87	(30)
Louise Gifford
Introduction	87	(2)
Financial Responsibilities in Nursing	89	(1)
Building the Labor Budget	90	(8)
Direct Care Labor Costs	90	(8)
Labor Budget Implementation Plan	98	(11)
Acuity	103	(1)
Monitoring and Analyzing the Labor Budget	104	(3)
Reporting Justification	107	(2)
Materials and Supplies	109	(5)
Assessment of Needs	109	(1)
Developing the Budget Worksheet	110	(1)
Monthly Monitoring of the Budget	111	(3)
Summary	114	(2)
References	116	(1)
Ignoring the Patient Classification System---Another Way to Staff	117	(40)
Kathryn W. Wilhoit
Jane M. Mustain
Introduction to Nursing Hours per Patient Day-Based Staffing	117	(1)
Personal Reflections: Why Choose This Method	118	(1)
Making Staffing Decisions Without Using a Patient Classification System	119	(7)
Nurse Manager/Expert	119	(1)
Budget	120	(1)
Benchmarking	120	(6)
Nurse Consultant	126	(1)
Facility-Specific Historical Data	126	(1)
Determining Staff Mix	126	(1)
Selected Unit of Measurement: Nursing Hours per Patient Day	127	(1)
Calculation of Unit-Specific Total Patient Days	128	(1)
Daily Staffing Needs Calculation	129	(1)
Calculation of NHPPD	130	(1)
Budgeted NHPPD	130	(1)
Targeted NHPPD	130	(1)
Core Staffing Plan Development	131	(2)
Direct versus Indirect Care Hours	132	(1)
Developing a Core Staffing Plan	133	(5)
Step 1	134	(1)
Step 2	135	(1)
Step 3	135	(3)
Step 4	138	(1)
Determining Staff Mix	138	(3)
Measuring Success	141	(4)
Implementing a Unit-Specific NHPPD-Based Staffing Plan	145	(1)
Discussion of Sample Unit Staffing Plan	146	(1)
Evaluation of This Staffing Method	147	(7)
Daily Review and Revision	147	(1)
Trending of Staffing Data	148	(1)
Bi-Weekly Review	149	(1)
Monthly and Longer-Term Review	149	(4)
Chief Nursing Executive Evaluation	153	(1)
Conclusions: Judging This Plan's Success	154	(2)
References	156	(1)
Acuity-Based Flexible Nursing Budgets	157	(22)
Coy L. Smith
Introduction	157	(2)
Variable, Fixed, and Overhead Expenses	159	(2)
Variable Cost Centers and Products	161	(1)
Establishing the Variable Budget	161	(1)
Projecting Budgeted Volumes	162	(2)
Developing the Variable and Fixed Salary Budget	164	(7)
Comments Related to the Variable Salary Budgets	171	(1)
Staff Mix	171	(1)
Prudent Budget Methodology	171	(1)
Budgetary Decision Making and Negotiation	172	(1)
Variable Non-Salary Line Items	172	(1)
Fixed Supply Component	173	(1)
The Final Variable Budget	174	(1)
Conclusion	175	(2)
References	177	(2)
Part II Long-Term Care Issues	179	(92)
Managing Long-Term Care Resources	181	(38)
Frances W. ``Billie'' Sills
Susie Hutchings
Introduction	181	(5)
Who Needs Long-Term Care?	186	(3)
Types of Long-Term Care Facilities	189	(1)
Ownership	189	(1)
Accountability in Long-Term Care	190	(2)
The Federal Long-Term Care Survey and Regulation Process	192	(7)
Resident Rights, Quality of Life, and Quality of Care	192	(1)
Staffing and Services	193	(1)
Resident Assessment	193	(1)
Federal Standards and Survey Procedures	194	(1)
Enforcement Procedures	194	(3)
Avoidable or Unavoidable Issues	197	(2)
Investigating Resistants Use	199	(1)
The Future of Governmental Guidance Regarding Surveys	199	(3)
Ethical Decision-Making in Long-Term Care	202	(2)
The Use of Agents and Directives	204	(1)
Withholding or Withdrawing Medical Treatment	204	(1)
``Do Not Transfer'' and ``Do Not Hospitalize'' Decisions	205	(1)
Reimbursement in Long-Term Care	205	(3)
Private Pay	206	(1)
Medicare	206	(1)
Medicaid	207	(1)
Veterans Administration (VA)	207	(1)
Other Models	207	(1)
The Budgetary Process	208	(1)
Staffing and Scheduling	209	(2)
Nursing's Role in Long-Term Care	211	(2)
American Nurses Credentialing Center (ANCC) Magnet Program: Recognizing Excellence in Nursing Services	213	(1)
Key Players in Long-Term Care Facilities	213	(1)
Conclusion	214	(1)
References	214	(1)
Helpful Websites	215	(1)
Appendix Nursing Assistant Mentor Program Curriculum	216	(3)
The Resident Assessment Instrument (RAI): The Minimum Data Set (MDS)	219	(24)
Steven B. Littlehale
Cheryl Field
Diane L. Brown
Historical Background	220	(3)
The Resident Assessment Instrument (RAI)	223	(7)
The Minimum Data Set	224	(3)
Assessment Reference Dates and Corresponding Dates for Payment	227	(2)
Triggers and Resident Assessment Protocols	229	(1)
The Current 44 RUG-III Categories	230	(8)
Determination of Facility-Specific Per Diem Rates	230	(2)
Inpatient Rehabilitation Post-Payment System	232	(1)
Development of MDS 3.0---Original Timeline 2005	232	(1)
The Care Plan	233	(1)
Utilization Review	233	(1)
Key Elements for Accurate Assessment	234	(1)
Reliability and Validity of the MDS v2.0	235	(1)
The Consequences of Inaccurate Assessment	235	(3)
Implications for Nurse Administrators	238	(1)
Strategies for PPS Operations Management	238	(3)
Get Smart with ARD Dates!	239	(1)
Put Expectations in Writing	239	(1)
Check and Change Documentation Systems	240	(1)
Communication	240	(1)
Interdisciplinary Team (IDT) Function	241	(1)
Conclusion	241	(1)
References	241	(2)
An Interdisciplinary Approach to the MDS	243	(28)
Amy M. Cripps
Brief History	243	(1)
Overview of the Minimum Data Set	244	(1)
Skillable Services	245	(4)
Specifics of Resource Utilization Groups	249	(6)
Other Medicare-Required Assessments	255	(1)
Case Study	256	(2)
Resident Assessment Instrument	258	(3)
Minimum Data Set	259	(1)
Resident Assessment Protocols	260	(1)
Plan of Care	260	(1)
Connection to Quality Indicators	261	(1)
Avoiding Fraud	262	(1)
Conclusion	263	(1)
References	263	(1)
Resources	264	(1)
Appendix Minimum Data Set (MDS)--Version 2.0	265	(6)
Part III Home Care Issues	271	(52)
Introduction to Home Health Care	273	(18)
Gail Gerding
Karen Cober
Introduction	273	(1)
History and Growth of an Industry	274	(3)
Qualifying for Home Health Care	277	(1)
Types of Services Provided in Home Care	278	(2)
Who Pays For Home Health?	278	(2)
Types of Home Care Agencies	280	(2)
Characteristics of Home Care Users	282	(2)
Diagnosis	283	(1)
Reason For Discharge	283	(1)
Case Mix	283	(1)
Why the Change in Home Health Reimbursement?	284	(1)
OASIS and the Prospective Payment System	284	(2)
Home Health Coding	286	(1)
Summary	286	(1)
References	287	(4)
Putting It All Together: Managing Resources in a Home Health Agency	291	(32)
Karen Cober
Introduction	291	(1)
Barriers to Budgeting Success	292	(2)
Agency Types	294	(2)
The For-Profit Agency	294	(1)
The Not-for-Profit Agency	295	(1)
Agency Case Mix and Size	295	(1)
Is the Agency Freestanding or Hospital-Based?	296	(3)
New or Established?	297	(1)
Niche versus One-Stop-Shop	298	(1)
Budget Types	299	(3)
The Budgeting Process	301	(1)
Revenue	302	(5)
Payor Type	303	(1)
Charges and Reimbursement	304	(2)
How Many? How Sick? Who Pays?	306	(1)
Expenses	307	(3)
Costing Out a Service	308	(2)
Staffing and Salary Expense	310	(7)
Direct Expense: FTEs	310	(1)
Staffing Models	310	(1)
Staff Reimbursement Models	311	(2)
Productivity and FTEs	313	(2)
Indirect Expense	315	(2)
Defending Your Budget	317	(1)
Budget Variances: Evaluating the Budget Throughout the Year	318	(2)
Conclusion: Future Challenges	320	(1)
References	321	(1)
Helpful References and Websites	321	(2)
Part IV Ambulatory Care Issues	323	(78)
Nurse Practitioner Reimbursement in Primary Care	325	(46)
Carol Lee Logan
Introduction	325	(1)
Primary Care Settings	326	(3)
Private Practice Offices/Contracted Services	326	(1)
Rural Health Clinic	326	(1)
Federally Qualified Health Center	327	(1)
Rural Health Clinic versus Federally Qualified Health Center	327	(2)
Who Reimburses Advanced Nurse Practitioners?	329	(3)
Medicare	329	(1)
Medicaid	330	(1)
Commercial Indemnity Insurers	331	(1)
Managed Care Organizations	331	(1)
Business/Agency Contracts	331	(1)
Credentialing Requirements	332	(1)
An Introduction to Third Party Reimbursement	332	(3)
Basic Steps of Medical Billing	334	(1)
Administrative Operations	335	(15)
Policies and Procedures	335	(3)
Forms and Documents	338	(1)
Fee Schedules	339	(2)
Procedure Coding with CPT and HCPCS	341	(1)
Key Points Regarding Current Procedural Terminology (CPT) and Health Care Financing Administration Common Procedure Coding System (HCPCS)	341	(1)
Structure of CPT and HCPCS	342	(1)
Current Procedural Terminology (CPT) Modifiers	343	(1)
National Level II HCPCS	343	(1)
National Level II Modifiers	344	(1)
Procedure Coding	344	(4)
Diagnosis Coding with ICD-9-CM	348	(2)
Third-Party Reimbursement---Dealing with Insurance Carriers	350	(1)
Medicare	350	(1)
Medicaid	350	(1)
Commercial Third-Party Payers	351	(1)
Managed Care Organizations (MCO)	351	(1)
Conclusion	351	(1)
References	352	(1)
Appendix A	353	(3)
Appendix B	356	(1)
Appendix C-1	357	(2)
Appendix C-2	359	(1)
Appendix C-3	360	(3)
Appendix C-4	363	(1)
Appendix C-5	364	(2)
Appendix D	366	(2)
Appendix E	368	(3)
Managing Resources/Budgeting in Ambulatory Care	371	(30)
Beth A. Cherry
Introduction	371	(1)
Preparing the Capital Budget	372	(1)
Preparing the Operating Budget	372	(2)
Components of a Budget	374	(8)
Revenue	374	(1)
Expenses: Salaries and Benefits	374	(3)
Expenses: Supplies and Equipment	377	(1)
Expenses: Indirect Costs	377	(1)
Contribution Margins	377	(5)
Net Income	382	(1)
Volume Projections	382	(1)
Visits	382	(1)
Procedures and Surgeries	383	(1)
Determining Reimbursement Rates	383	(4)
Charges and Costing Out of Services	387	(8)
Understanding the Budget Sheet	395	(3)
Understanding Relative Value Units (RVU)	398	(1)
Patient Satisfaction and Impact on the Budget	398	(1)
Conclusion	399	(1)
References	399	(2)
Index	401