Chapter 3 - Working In Health Care

Question 1

Licensure

P. 47

Answer 1

A mandatory credentialing process established by law, usually at the state level, that grants the right to practice certain skills and endeavors.

Question 2

Reciprocity

P. 47

Answer 2

The process by which a professional license obtained in one state may be accepted as valid in other states by prior agreement without re-examination.

Question 3

Endorsement

P. 48

Answer 3

Is a process by which a license may be awarded based on individual credentials judged to meet licensing requirements in the new state of residence.

Question 4

In some situations, Physicians do not need a valid license to practice medicine in a specific State. These situations include the following:

(P. 48)

Answer 4

• when responding to emergencies
• while establishing state residency requirements in order to obtain a license
• when employed by the US Armed Forces, Public Health Service, Veterans Administration, or other Federal facility
• when engaged solely in research and not treating patients

Question 5

Periodic license renewal

P. 48

Answer 5

Is necessary; this usually requires simply paying a fee however, many states require proof of continuing education units for license renewal.

Question 6

The 10 most common reasons for loss of License to practice, which is applicable to most health care practitioner licenses are:

(P. 48)

Answer 6

• sexual misconduct
• substance abuse
• professional discipline (for) criminal convictions or unprofessional conduct
• fraud and misrepresentation
• patient abuse
• medication violations
• unethical Behavior
• poor documentation or record keeping
• Unlicensed practice (“forgetting” to renew a license is no defense.)

Question 7

Certification

P. 49

Answer 7

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

Question 8

Registration

P. 49

Answer 8

A credentialing procedure whereby one’s name is listed on a register as having paid a fee and/or met certain criteria within a profession.

Question 9

Scope of practice

P. 50

Answer 9

The determination of the duties/procedures that a person may or may not perform under the auspices of a specific Healthcare professionals license.

Question 10

Accreditation

P. 51

Answer 10

Official authorization or approval for conforming to a specified standard for healthcare educational programs, Healthcare facilities, and Managed Care Facilities.

Question 11

The Joint Commission (TJC)

P. 51

Answer 11

Is an independent, non-for-profit organization that accredits many types of healthcare organizations.

• General, psychiatric, children’s, and Rehabilitation hospitals
• critical access hospitals
• Home Care organizations
• nursing homes in other long-term care facilities
• assisted living facilities
• Behavioral Healthcare organizations
• Ambulatory Care providers
• clinical laboratories

Question 12

To earn and maintain The Joint Commission (TJC) accreditation, an organization must undergo….

(P. 51)

Answer 12

an on-sight survey buy a TJC survey team at least every three years. Laboratories must be surveyed every two years.

Question 13

Agencies that provide accreditation and establish standards for healthcare delivery include the following:

(P. 52)

Answer 13

• The Joint Commission (TJC)
• National Committee for Quality Assurance (NCQA)
• Utilization Review Accreditation Commission (URAC)
• Accreditation Association for Ambulatory Health Care (AAAHC)

Question 14

The National Committee for Quality Assurance (NCQA), an independent, nonprofit organization that evaluates and reports on the quality of the nation’s managed care organizations. NCQA evaluates managed care programs in three ways:

(P. 52)

Answer 14

1. Through on-site reviews of key clinical and administrative processes.
2. Through the healthcare Effectiveness Data and Information Set (HEDIS)– data
   used to measure performance in areas such as immunization and mammography screening rates.
3. Through use of member satisfaction surveys.

• Participation in NCQA accreditation and certification programs is voluntary.

Question 15

Accrediting agencies for healthcare education programs evaluate the effectiveness of a program in terms of …..

(P. 52)

Answer 15

How well it prepares students to meet broad and specific professional standards.

Question 16

The Commission on Accreditation of Allied Health Education Programs (CAAHEP)

(P. 53)

Answer 16

Oversees the accreditation process of a variety of individual allied health educational program. There are 28 different allied health professionals under the CAAHEP umbrella.

Question 17

Accrediting Bureau of Health Education Schools (ABHES)

P. 53

Answer 17

Does both institutional accreditation of schools of allied health and program specific accreditation.

(Medical assisting programs may be accredited by Medical Assisting Educational Review Board (MAERB) or Accreding Bureau of Health Education Schools (ABHES).)

Question 18

Medical Practice Acts

P. 55

Answer 18

State laws written for the express purpose of governing the practice of Medicine.

• each state periodically revised has its medical practice acts to keep them current with the times.

Question 19

Medical boards

P. 55

Answer 19

Bodies established by the authority of each state’s medical practice acts for the purpose of protecting the health, safety, and welfare of healthcare consumers through proper licensing and regulation of physicians and other healthcare practitioners.

• funding for State Medical boards comes from licensing and registration fees.

Question 20

Applicants for license must generally:

P. 56

Answer 20

• provide proof of education and training.
• provide details about their work history.
• pass an examination designed to access their knowledge and their ability to apply that knowledge and other concepts and principles important to ensure safe and effective patient care.
• reveal information about their past medical history (including alcohol and drug abuse), arrest, and convictions.

Question 21

Each State’s Medical Practice acts also define unprofessional conduct for medical professionals. Laws vary from state to state, but examples of unprofessional conduct include:

(P. 56)

Answer 21

• physical abuse of a patient
• inadequate record keeping
• failure to recognize or act on common symptoms
• prescribing drugs in excessive amount or without legitimate reason
• impaired ability to practice due to addiction or physical or mental illness
• failure to meet continuing education requirements
• performance of duties beyond the scope of a license
• conviction of a felony
• delegation of the practice of medicine to an unlicensed individual

Question 22

A healthcare professional could be considered guilty of fraud if “intent to deceive” can be shown. Axe generally classified as fraud include:

(P. 57)

Answer 22

• falsifying educational degrees, applications for licenses, licenses, or other credentials
• feeling a governmental Agency for services not rendered
• falsifying medical reports
• falsely advertising or misrepresenting to a patient “secret cures” or special powers to cure an ailment

Question 23

Revocations and suspensions of license are never automatic. A physician is always entitled to a written description of charges against him or her and a hearing before the appropriate _________ agency. If a hearing is held, the physician also has the right to counsel, the right to present evidence in his or her defense, the right to confront and question witnesses, and any other rights granted by ________ law.

(P. 57)

Answer 23

state; state.

Question 24

Healthcare practitioners often work together as a team to provide medical care to patients, each individual is _________ able to perform only those duties dictated by professional and statutory guidelines. Each health care practitioner is responsible for understanding the laws and rules pertaining to his or her job and knowing _________ concerning renewal of licenses, recertification, and payment of fees for licensure, certification, and registration.

(P. 57)

Answer 24

legally; requirements.

Question 25

The days have passed (before 1960) when there were two major classifications for old patient Healthcare Management:

(P. 58)

Answer 25

Sole proprietorship and group practice.

Question 26

Professional Corporation

P. 58

Answer 26

A body formed and authorized by law to act as a single person.

Question 27

Managed Care Organization (MCO)

P. 58

Answer 27

A corporation that links Health Care financing, Administration, and Service delivery.

Question 28

Managed Care

P. 59

Answer 28

A system in which financing, Administration, and delivery of healthcare are combined to provide medical services to subscribers for a prepaid fee.

• the payment from a managed care plan to Providers maybe one of several types, including contracted fee schedules, percentages of billed charges, capitalization, and others.

Question 29

Capitalization

P. 59

Answer 29

Is a set advance payment made to Providers, based on the calculated cost of medical care of a specific population of subscribers.

Question 30

Coinsurance

P. 59

Answer 30

Refers to the amount of money insurance plan members must pay out of pocket, after the insurance plan pays its share.

• For example, a plan me agreed to pay 80% of the cost for a surgical procedure, and the subscriber must pay the remaining 20%.

Question 31

Copayment fees

P. 59

Answer 31

are flat fees that insurance plan subscribers pay for certain Medical Services.

• For example, a subscriber might be required to make a $20 copayment for each visit to a physician’s office.

Question 32

Deductible

P. 59

Answer 32

Amounts are specified by the insurance plan for each subscriber.

• For instance, the deductible for a single subscriber might be $500 a calendar year. In other words, the plan does not begin to pay benefits until the $500 deductible has been satisfied.

Question 33

Formularies

P. 59

Answer 33

Are a plan’s list of approved prescription medications for which it will reimburse subscribers.

Question 34

Utilization review

P. 59

Answer 34

Is the method used by a health plan to measure the amount of appropriateness of health services use by its members.

Question 35

Health maintenance organization (HMO)

P. 59

Answer 35

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

• under HMO plans, all health services are delivered and paid for through one organization. The two general types of HMOs are group model and staff model.

Question 36

Preferred provider organization (PPO)

P. 60

Answer 36

A network of independent Physicians, hospitals, and other healthcare 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).

Question 37

Preferred Provider Organizations (PPO), also called Preferred provider associations (PPA)

(P. 60)

Answer 37

Are managed care plans that contract with a network of Doctors, Hospitals, and other healthcare providers who provide services for set fees.

Question 38

Physician-Hospital organization (PHO)

P. 60

Answer 38

A healthcare plan in which positions join with hospitals to provide a medical care delivery system and then contract for insurance with a commercial carrier or an HMO.

• PHOs are organizations that include Physicians, hospitals, surgery centers, nursing homes, Laboratories, and other medical service providers that contract with one or more HMOs, insurance plans, or directly with employers to provide health care services.

Question 39

Medical Services organization

P. 60

Answer 39

A Physician group purchases a hospital, which then contracts with employers to provide full health care services.

Question 40

Exclusive provider organization (EPO)

P. 60

Answer 40

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

Question 41

Health reimbursement Arrangement or account (HRA)

P. 60

Answer 41

In employer-funded, tax-advantaged employer health benefit plan provided 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 amount employers pay contribute to an HRA.

Question 42

Health savings account (HSA)

P. 60

Answer 42

Offered to individuals covered by high-deductible health plans, these accounts let these individuals save money, tax-free, to pay for medical expenses.

Question 43

Independent practice Association

P. 61

Answer 43

A type of HMO that contracts with groups of the Physicians who practice in their own offices and receive a premember payment (capitalization) from participating HMOs to provide a full range of health services for members.

Question 44

Primary care physician (PCP)

P. 61

Answer 44

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

Question 45

Open Access plan

P. 61

Answer 45

Under Open Access plans, subscribers may see any in-network healthcare provider without a referral.

Question 46

Point of service (POS) plan

P. 61

Answer 46

The insured chooses a primary care physician (PCP) from a list of participating providers. The primary care physician may make referrals to other network providers when needed. Patients desiring to visit in out-of-pocket providers still need a referral, and there may be higher out-of-network charges.

Question 47

Health insurance portability and accountability Act (HIPPA) of 1996

(P. 62)

Answer 47

Federal statute that helps workers keep continuous health insurance coverage for themselves and their dependents when they change jobs, protect confidential medical information from unauthorized disclosure or use, and help curb the rising cost of Fraud and Abuse.

Question 48

The primary objectives of the HIPAA law were to:

P. 63

Answer 48

1. Improve the efficiency and effectiveness of the healthcare industry by:
   • accelerating billing processes and reducing paperwork
   • reducing Health care billing fraud
   • facilitating tracking of health information
   • improving accuracy and reliability of shared data
   • increasing access to computer networks within health care facilities
2. Help employees keep their health insurance coverage when transferring to another job.
3. Protect confidential medical information that identifies patients from unauthorized disclosure or use.

Question 49

National Practitioner Data Bank (HIPDB)

P. 63

Answer 49

Is a national Healthcare Fraud and Abuse data collection program for the reporting and disclosure of certain adverse actions taken against Healthcare Providers, suppliers, or practitioners.

Question 50

Patient protection and Affordable Care Act (PPACA, also abbreviated ACA)

(P. 63)

Answer 50

A federal law enacted in 2010 to expand health insurance coverage and otherwise regulate the health insurance industry.

Question 51

The ACA was extensive in its regulation but the key features for clients paying for Health Plan coverage were as follows:

(P. 63)

Answer 51

• children under nineteen can no longer be excluded from coverage due to pre-existing conditions.
• children under 26 can be covered by their parents’ health plans.
• insurers cannot cancel coverage because clients make simple mistakes in applying for insurance or in other correspondence.
• if a plan denies coverage, clients have the right to appeal.
• Health Plan coverage must include certain recommended preventive Health Services.
• clients can choose the primary care provider they want from their plan’s network of participating providers.
• clients can seek Emergency Services outside their health plans Network.
• Lifetime dollar limits imposed by health care plans are eliminated.
• if a client can’t afford health insurance but chooses not to buy it, that person must pay a penalty, which is collected through federal tax forms.

Question 52

Health Care education and Reconciliation Act (HCERA)

P. 63

Answer 52

Enacted in 2010, a federal law that added to regulations imposed on the insurance industry by PPACA.

Question 53

The PPACA or ACA also established a health insurance Marketplace, a resource where individuals, families, and small businesses can:

(P. 64)

Answer 53

• learn about their coverage options.
• compare health insurance plans based on costs, benefits, and other features.
• choose a plan in enroll in coverage.

Question 54

Accountable Care Organization

P. 64

Answer 54

A health care payment and delivery model that rewards doctors and hospitals for controlling costs and improving outcomes by allowing them to keep a portion of the savings is standards of quality are met.

Question 55

The ACA encouraged Healthcare in serves to unite with health care providers to form ___________ ________ _________ (______), the moving the healthcare system from the current fee-for-service based to a valued based system.

(P. 64)

Answer 55

Accountable care organizations (ACOs)

Question 56

The Accountable Care Organization care model emphasized:

P. 64

Answer 56

Preventive care, Healthcare team coordination, electronic health records, treatment based on proof of effectiveness, and day or night access for patients.

• Those ACOs that met quality standards might also reward doctors and hospitals for controlling costs and improving patient outcomes by allowing them to keep a portion of savings.

Question 57

Allopathic

P. ?

Answer 57

“Different suffering” referring to the medical philosophy that dictate training Physicians to intervene in the disease process, through the use of drugs and surgery.

Question 58

Patient portal

P. ?

Answer 58

A secure online website that gives patients 24-hour availability to healthcare providers.