Health Care Systems and Settings Flashcards
What do MAs do
- perform administrative and clinical procedures and responsibilities
- screen pts before provider visit
Role of MA
- work alongside a provider in an outpatient or ambulatory setting
- administrative and clinical (crosstrained)
administrative duties of MA
- greeting pts
- handling correspondence
- answering phones
clinical duties of MA
- medical histories
- explaining treatments or procedures
- drawing lab tests
- preparing and administering immunizations
Medical Doctors MD
- allopathic providers
- diagnose
- treat
- procedures
- prescriptions
Osteopathic providers DO
-use osteopathic manipulative therapy (OMT) in treating pts
nurse practitioners
- basic pt care service
- diagnosing
- prescribing
- preventive care
- disease prevention
physician assistant
-under the direction and supervision of MD or DO
medical lab tech
- diagnostic testing on blood, bodily fluids
- under supervision of medical tech
medical receptionist
- check pts in and out
- answer phones
- perform filing, faxing etc
occupational therapist
-assist pts who are disabled
pharmacy tech
-assist with duties that dont require the expertise or judgement of a licensed pharmascist
physical therapist
-assist pts in regaining mobility and improving strength/motion
radiology tech
-use imaging equipment to assist provider in diagnosing and treating
additional credentials for MA
- phlebotomy
- EKG
- billing and coding
- electronic health records
- health coach or pt navigator
accountable care organizations (ACOs)
- voluntarily provide coordinated high quality care to medicare pts
- share in the savings it achieves for the medicare program
capitation (partial or full)
-pts are assigned per-member, per-month payment based on age, race, sex, lifestyle, medical history, and benefit design
global budget
- fixed total dollar amount paid annually for all care
- limits the level and rate of increase of health care cost
health maintenance organization (HMO)
- contracts with medical center or group of providers to provide care to insured persons
- usually require referrals
patient center medical home (PCMH)
- primary care provider coordinates treatment
- comprehensive care, pt-centered care, coordinated care, accessible services, quality and safety
- emphasizes pts involvement in organizing their own health care
pay for performance
-compensates providers only if they meet certain measure for quality and efficiency
preferred provider organization (PPO)
- flexible
- pt can go directly to specialist without referral
- can see providers in and out of network
general practitioners (GPs)
- medical doctors who treat acute and chronic illnesses
- may take holistic approach -> considers biological, psychological, and social aspects of care
- general
family practitioners
- offers care to whole family
- preventive care
- general
internists
- comprehensive care of adults
- chronic long term conditions
- general
specialized practices
- allergist
- anesthesiologist
- cardiologist
- dermatologist
- endocrinologist
- gastroenterologist
- gynecologist
- hematologist
- hepatologist
- neonatologist
- nephrologist
- obstetricians (preg)
- oncologist
- ophthalmologist
- orthopedists
- otolaryngologist
- neurologist
- pathologist
- pediatricians
- psychiatrists
- radiologist
- urologist
ancillary service
- provides convenience for pts
- meet specific medical need for a specific population
- ex. occupational therapist- assist pts in day to day tasks
- ex. urgent care- more locations and flexibility
- labs
- diagnostic imaging
- physical therapy
alternative therapies
- acupuncture
- chiropractic
- energy therapy
- dietary supplements
advanced beneficiary notice (ABN)
-form when provider believes medicare will not pay for services received
allowed amount
-maximum amount a third party payer will pay for a service
copayment
-amount of money that is paid at time of medical service
coinsurance
- policyholder and insurance company share the cost of covered losses in a specified ratio
- ex. 80:20
deductible
-specific amount of money a pt must pay out of pocket before the insurance carrier begins paying
explanation of benefits
- statement from the insurance carrier detailing what was paid, denied, or reduced in payment
- contains information about amounts applied to the deductible, coinsurance and allowed amounts
participating provider (PAR)
-providers who agree to write off the difference between the amount charged by the provider and the approved fee established the insurer
federal and state government plans
- medicare
- tricare
- CHAMPVA
- medicaid
- managed care plans
- workers compensation
medicare
- 65 and older
- by hospitalization or routine medical office visits
tricare
-military personnel to receive treatment from civilian providers
CHAMPVA
-covers surviving spouses and dependent children of veterans who died
medicaid
-health care for medically indigent population through cost sharing program between federal and state government
managed care
-plans that provide health care in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals
workers compensation
-protects wage earners against the loss of wages and cost of medical care resulting from occupational accident or disease
private insurance
- blue cross blue shield
- aetna
- united healthcare
- 2 basic managed care models:
- preferred provider organization PPO- flexibility in changing PCPs around
- health maintenance organizations HMO- require to choose a PCP
PCP
-primary care provider
CMS-1500 form
- health insurance claim form for claims submitted by a provider or supplier
- MA needs pts and guarantors demographic and insurance information, diagnostic test, treatment, procedure info, and billing info
- 33 blocks or items divided into 3 sections
CMS-1500 form sections
- carrier block- address of insurance carrier
- pt insured section- info about pt (1-13)
- physician/supplier section- info about physician (14-33)
administrative simplification compliance act (ASCA)
- requires that claims to medicare by transmitted electronically
- submitted electronically through billing or to a claim clearing house
- must be no later than 12 months after date of service
CPOE
computerized provider order entry
lincensure
- state regulated
- issued upon graduation
- not required for MA
certification
- generally optional
- requires continuing education to keep current
who is responsible for the MA
-licensed health care professional
preventive medicine specailist
- evaluates mental illness, physical illness, and disability by analyzing pt health needs
- all ages
blue cross blue shield
-oldest and largest insurance
vertigo
otolaryngologist
-eyes nose ear disease
require a license
- PA
- radiologist
- anesthesiologist
- MA
- DO
exclusive provider organization (EPO)
- shares features of HMO and PPO
- pts can choose from a network of providers
- do not need referral to see specialist
fee schedule
-list of charges for procedures and services performed in the providers office
subluxation
- dislocation, misalignment
- treated by chiropractic care
biofeedback
- help pts relax by recognizing bodily functions
- teaches pts how to control physiologic responses to stress
home health agency
-provide pts with in home services
