Healthcare Systems & Settings Exam Flashcards
Diagnose illness, provide treatments, perform procedures, and write prescriptions
Medical doctors
Do osteopathic manipulative therapy (OMT) to treat patients
Osteopathic providers (DO’s)
Advanced training beyond RN degree, extensive clinical experience, diagnose and treat common illness, and focus on preventive care
Nurse practitioners
Practice medicine under MD or DO, advanced degree
Physician assistant
Diagnostic testing on blood under supervision of medical technologist
Medical laboratory technicians
Check patients in and out, answer, phones, perform feeling, faxing, and other tasks
Medical receptionist
HMO
Health maintenance organization
PPO
Preferred provider organization
ACO
Accountable care organization (capitation)
PCMH
Patient centered medical home (global budget, pay for performance)
-provides lower costs to plan members
-requires a referral from a PCP to to see specialist
-requires pre-authorization for surgery
HMO
-provides lower cost of plan members
-less restrictions to see specialist
-can go out of network providers, but will cost more
PPO
Provider network sharing financial and medical responsibility for coordinated patient care, for Medicare patients, ACA (In hopes of limiting unnecessary spending)
Accountable care organizations (ACO)
Payment to physician per patient, per time period in advance, and incentives avoiding costly procedures based on demographics
Capitation (full or partial)
Primary care provider (PCP) coordinates treatment for patient to ensure they receive necessary care (patient centered)
(PCMH) patient centered medical home
Physicians receive fixed payments for patient care, encouraging, cost-effective treatment choices based on in individual factors
Global budget
Providers paid for meeting, quality and efficiency criteria
Pay for performance
Appropriate dress, personal phone use, punctuality, and respect for boundaries
Professionalism
Lifelong goals
Intrinsic Motivation
Driven by outside forces, short and less fulfilling
Extrinsic motivation
Integrity, accountability, flexibility, and open mindness
Work ethic
Delegated to medical assistance, work under supervision
Scope of pratice
The degree of care or competence expected in a particular circumstance or role
Standard of care
What can MA not do?
Diagnosed, treat, or instruct patients to take course of action
What are the types of insurances?
Medicare, Medicaid, TRICARE, SCAMPVA, Worker’s Compensation, and private insurance plans
Covers patients 65+ by part A (hospitalization) or part B (routine office visits)
Medicare
Provides health insurance to low income individuals
Medicaid
Allows dependents of military personal to receive treatment from civilian providers
TRICARE
Covers surviving spouses and dependent children of veterans who died as a result of their service
CHAMPVA
Covers the cost of medical, resulting from a job injury or accident
Worker’s Compensation
Medical coverage purchased directly by an individual
Private insurance
Maximum amount and insurance company will pay for a procedure or service
Allowed amount
Amount of money paid by the patient for service or prescription
Copayment
Patient and insurance company share the cost in a specified ration, such as 80/20
Coinsurance
specific amount of money a patient must pay out-of-pocket before the insurance carrier begins paying
Deductible
Amount of money paid by the patient (usually money/per paycheck) to have medical insurance, cost often shared between employer and employee
Premium
Statement from the insurance company detailing what was paid, denied, reduced, etc
Explanation of benefits
Provider agrees to write off the difference between the amount charge and the approved fee established by the insurance company
Participating provider
organization that individual is qualified to perform job to professional standards (non-governmental agency/association)
Certification
Granting of the title or licensed by board that gives you permission to practice chosen profession (wear pin), usually bored or governmental association
Registration
