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1430-59 Legal Principles of Health Information > Chapter 3 > Flashcards

Chapter 3 Flashcards

1
Q

licensure *

A
  • a mandatory credentialing process established by law, usually at the state level, that grants the right to practice certain skills and endeavors
  • required in every state for physicians, nurses, and other health care practitioners
  • licenses for health care professionals to practice can be revoked or suspended in certain circumstances
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2
Q

reciprocity*

A

the process by which a professional license obtained in one state may be accepted as valid in other states by prior agreement without reexamination

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3
Q

scope of practice*

A
  • the determination of the duties/procedures that a person may or may not perform under the auspices of a specific health care professional’s license
  • duties determined by each state’s laws, regulations, educational requirements, and licensing bodies
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4
Q

accreditation *

A
  • official authorization or approval for conforming to a specified standard for health care education programs, health care facilities, and managed care facilities
  • usually voluntary
  • health care organization such as hospitals, patient care facilities, and health plans are accredited
  • health care education organizations are accredited
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5
Q

practice acts*

A

state laws written for the express purpose of governing the practice of specific health care professions

  • define practice of individual health professions in each state
  • explain requirements and methods for licensure
  • establish licensing boards
  • establish grounds for suspension or revocation of license
  • give conditions for license renewal
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6
Q

professional boards*

A

bodies established by the authority of each state’s practice acts for the purpose of protecting the health, safety, and welfare of health care consumers through proper licensing and regulation of health care practitioners.

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7
Q

managed care organization (MCO) *

A

a system in which corporation that links, health care financing, administration, and delivery of health care services that are combined to provide medical services to subscribers for a specific fee

may take form of:

  • contracted fee schedules
  • percentage of fees
  • capitation
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8
Q

managed care *

A

a system in which financing, administration , and delivery of health care are combined to provide medical services to subscribers for prepaid fee.

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9
Q

health maintenance organization (HMO) *

A

a health plan that combines coverage of health care costs and delivery of health care for a specific payment

  • all services are delivered and paid for through one organization.
  • 2 types = group model and staff model
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10
Q

preferred provider organization/association (PPO/PPA)*

A

a network of independent physicians, hospitals, and other health care providers who contract with an insurance carrier to provide medical care at a discount rate to patients who are part of the insurer’s plan. Also called preferred provider association (PPA)

  • provide services for set fees
  • subscribers may choose their health providers from an approved list and must pay higher out of pocket costs for care provided by HCP outside the PPO group
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11
Q

physician-hospital organization (PHO)

A

a health care plan in which physicians join with hospitals to provide a medical care delivery system and then contract for insurance with a commercial carrier or an HMO

  • another type of managed care plan
  • contract with one or more HMOs, insurance plans, or directly with employers to provide health care services
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12
Q

Medical services organization (MSO) *

A

a physician group purchases a hospital which then contracts with employers to provide full health care services

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13
Q

exclusive provider organization (EPO) *

A

a managed care plan that pays for health care services only within the plans network of physicians, specialists, and hospitals (except in emergencies).

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14
Q

health reimbursement arrangement or account *

A

an employer-funded, tax-advantage employer health benefit plan approved by the internal revenue service (IRS) that reimburses employees for out-of-pocket medical expenses and individual health insurance premiums there are no annual limits on the amounts employers may contribute to an HRA

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15
Q

health savings account (HSA) *

A

offered to individuals covered by high-deductible health plans, theses accounts let these individuals save money, tax free, to pay for medical expenses. there are no yearly limits on amounts one may contribute to an HSA

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16
Q

high deductible health plan *

A

a plan with a higher deductible than a traditional insurance plan. the monthly premium is usually lower

-subscribers pay more health care costs themselves before the insurance company starts to pay its share (the deductible)

17
Q

independent practice association (IPA) *

A

a type of HMO that contracts with groups of physicians who practice in their own offices and receive a per-member payment (capitation) from participating HMOs to provide a full rang of health services for members

-is organized and owned by a network of independent physician practices to contract with employers and or managed care organizations such as PPOs or HMOs

18
Q

open access plan (OAP) *

A

subscribers may see any in-network health care provider without a referral

-both HMO and POS plans may offer open access features. However, the choice must be made from an approved directory of specialist or the member pays more of the associated cost

19
Q

point of service plan (POS)*

A

a primary care physician determines necessary services for the patient within a network

  • insured chooses the PCP from a list of participants
  • PCP may make referrals to other network providers when needed
  • patients who visit an out of network provider still needs a referral, and may be higher out of network charges
20
Q

primary care physician (PCP)*

A

the physician responsible for directing all of a patient’s medical care and determining whether the patient should be referred for specialty care

21
Q

patient centered medical home (PCMH)*

A

a form of managed care with a primary care provider developing a team-based approach to health care with an emphasis on preventive services, care coordination and access to care. the primary care provider receives higher reimbursement if goals are met

  • PCMH is practice specific
  • relatively new approach
  • offer incentives to providers to improve care
22
Q

accountable care organization (ACO) *

A

a pre-determined payment for providers who take care of a designated patient population, providers work together to provide care. Quality targets must be met

  • requires coordination and affiliation around multiple practices
  • lowering cost and improving patient out comes
  • offer financial intensives to improve care of a patient
  • new model
  • they have accreditation process through the joint commitee
23
Q

certification *

A

a voluntary credentialing process whereby applicants who meet specific requirements may receive a certificate

  • usually specific education and a national exam is required
  • example a CMA/AAMA (certified medical assistant/American Association of medical assistants)requires graduation from an accredited program and success in a national exam
24
Q

Registration*

A
  • historically was a credentialing procedure whereby ones name was listed on a register as having paid a fee and or met certain educational criteria within a profession
  • today is similar to the certification process
  • ex registered health information technician (RHIT) requires graduation from an accredited program and success in a national exam (American Health Information Management Association)
25
Q

Joint Commission Accreditation*

A

the organization is known as the TJC

Major accreditation agency for:

  • variety of hospitals
  • long-term care facilities (ex-nursing homes and assisted living)
  • clinical laboratories
  • ambulatory care (ex- outpatient surgery rehabilitation centers, and group practices).
26
Q

Educational Program Accreditation *

A
  • evaluate effectiveness of an educational program
  • does the program meet broad and specific professional standards?
  • appropriate laboratory and internship experiences.
  • are students able to pass licensure or certification exams?
27
Q

What types of third party payers are there in the Health Care Industry?

A
  1. for profit
  2. not for profit
  3. governmental health care providers
  4. companies that make health care products
28
Q

Managed Care Organizations (MCO) *

A

a system in which corporations link the financing, administration, and delivery of health care services that are combined to provide medical services to subscribers for a specific fee.

May take the form of:

  • contracted fee schedules
  • percentage of fees
  • capitation
29
Q

Patient centered medical home (PCMH) is

A
  • practice specific
  • relatively new model
  • care needs are centered around a primary care provider who develops a team approach to health care
  • emphasis prevention, care coordination, and access to care (ex- colonoscopy at age 50)
  • offer incentives to providers to improve care
30
Q

Group Model (HMO)

A

contract with independent groups of physicians to provide coordinated care for large numbers of HMO patients for a fixed, per-member fee.

  • provide medical care for members of several HMOs
  • include prepaid group practices (PGP)
  • physicians are salaried employees of HMO, usually practice in facilities provided by the HMO and share in profits at the end of the year
31
Q

Staff Model (HMO)

A
  • employed salaried physicians and other allied health professionals who provide care solely for members of HMO.
  • subscribers can often see their doctors, get lab tests and x rays, have prescriptions filled, and order eye glasses or contact lenses all in one location.
  • employ specialist or contract with outside specialist in some cases
32
Q

Physician Hospital Organization (PHO)*

A

a health care plans in which physician’s join with hospitals to provide a medical care delivery system and then contract for insurance with a commercial carries or HMO

33
Q

not for profit

A

turns more dollars back into the organization and growing the quality of organization

1430-59 Legal Principles of Health Information (8 decks)

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