Health Care Systems and Settings Flashcards
1
Q
What do MAs do
A
- perform administrative and clinical procedures and responsibilities
- screen pts before provider visit
2
Q
Role of MA
A
- work alongside a provider in an outpatient or ambulatory setting
- administrative and clinical (crosstrained)
3
Q
administrative duties of MA
A
- greeting pts
- handling correspondence
- answering phones
4
Q
clinical duties of MA
A
- medical histories
- explaining treatments or procedures
- drawing lab tests
- preparing and administering immunizations
5
Q
Medical Doctors MD
A
- allopathic providers
- diagnose
- treat
- procedures
- prescriptions
6
Q
Osteopathic providers DO
A
-use osteopathic manipulative therapy (OMT) in treating pts
7
Q
nurse practitioners
A
- basic pt care service
- diagnosing
- prescribing
- preventive care
- disease prevention
8
Q
physician assistant
A
-under the direction and supervision of MD or DO
9
Q
medical lab tech
A
- diagnostic testing on blood, bodily fluids
- under supervision of medical tech
10
Q
medical receptionist
A
- check pts in and out
- answer phones
- perform filing, faxing etc
11
Q
occupational therapist
A
-assist pts who are disabled
12
Q
pharmacy tech
A
-assist with duties that dont require the expertise or judgement of a licensed pharmascist
13
Q
physical therapist
A
-assist pts in regaining mobility and improving strength/motion
14
Q
radiology tech
A
-use imaging equipment to assist provider in diagnosing and treating
15
Q
additional credentials for MA
A
- phlebotomy
- EKG
- billing and coding
- electronic health records
- health coach or pt navigator
16
Q
accountable care organizations (ACOs)
A
- voluntarily provide coordinated high quality care to medicare pts
- share in the savings it achieves for the medicare program
17
Q
capitation (partial or full)
A
-pts are assigned per-member, per-month payment based on age, race, sex, lifestyle, medical history, and benefit design
18
Q
global budget
A
- fixed total dollar amount paid annually for all care
- limits the level and rate of increase of health care cost
19
Q
health maintenance organization (HMO)
A
- contracts with medical center or group of providers to provide care to insured persons
- usually require referrals
20
Q
patient center medical home (PCMH)
A
- 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
21
Q
pay for performance
A
-compensates providers only if they meet certain measure for quality and efficiency
22
Q
preferred provider organization (PPO)
A
- flexible
- pt can go directly to specialist without referral
- can see providers in and out of network
23
Q
general practitioners (GPs)
A
- medical doctors who treat acute and chronic illnesses
- may take holistic approach -> considers biological, psychological, and social aspects of care
- general
24
Q
family practitioners
A
- offers care to whole family
- preventive care
- general
25
internists
- comprehensive care of adults
- chronic long term conditions
- general
26
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
27
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
28
alternative therapies
- acupuncture
- chiropractic
- energy therapy
- dietary supplements
29
advanced beneficiary notice (ABN)
-form when provider believes medicare will not pay for services received
30
allowed amount
-maximum amount a third party payer will pay for a service
31
copayment
-amount of money that is paid at time of medical service
32
coinsurance
- policyholder and insurance company share the cost of covered losses in a specified ratio
- ex. 80:20
33
deductible
-specific amount of money a pt must pay out of pocket before the insurance carrier begins paying
34
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
35
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
36
federal and state government plans
- medicare
- tricare
- CHAMPVA
- medicaid
- managed care plans
- workers compensation
37
medicare
- 65 and older
| - by hospitalization or routine medical office visits
38
tricare
-military personnel to receive treatment from civilian providers
39
CHAMPVA
-covers surviving spouses and dependent children of veterans who died
40
medicaid
-health care for medically indigent population through cost sharing program between federal and state government
41
managed care
-plans that provide health care in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals
42
workers compensation
-protects wage earners against the loss of wages and cost of medical care resulting from occupational accident or disease
43
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
44
PCP
-primary care provider
45
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
46
CMS-1500 form sections
- 1. carrier block- address of insurance carrier
- 2. pt insured section- info about pt (1-13)
- 3. physician/supplier section- info about physician (14-33)
47
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
48
CPOE
computerized provider order entry
49
lincensure
- state regulated
- issued upon graduation
- not required for MA
50
certification
- generally optional
| - requires continuing education to keep current
51
who is responsible for the MA
-licensed health care professional
52
preventive medicine specailist
- evaluates mental illness, physical illness, and disability by analyzing pt health needs
- all ages
53
blue cross blue shield
-oldest and largest insurance
54
vertigo
otolaryngologist
| -eyes nose ear disease
55
require a license
- PA
- radiologist
- anesthesiologist
- MA
- DO
56
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
57
fee schedule
-list of charges for procedures and services performed in the providers office
58
subluxation
- dislocation, misalignment
| - treated by chiropractic care
59
biofeedback
- help pts relax by recognizing bodily functions
| - teaches pts how to control physiologic responses to stress
60
home health agency
-provide pts with in home services
