Ch 3

1. Ch 3 Working in Health Care

2. Learning Outcomes 3.1Define licensure, certification, registration, and accreditation. 3.2Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 3.3Discuss the composition of the health care team and the roles of its members. 3.4 Define the major types of medical practice management systems.

3. Learning Outcomes (cont.) 3.5Define the different types of managed care health plans. 3.6Discuss the federal legislation that impacts health care reimbursement and prohibits fraud and abuse in health care billing. 3.7Define telemedicine, cybermedicine, and e-health, and discuss their roles in today’s health care environment. 3-3

4. Licensure • Mandatory credentialing process established by law, usually at the state level • Required in every state for physicians, nurses, other health care practitioners

5. Certification • Voluntary credentialing process • Usually national in scope • Usually sponsored by a non- governmental, private-sector group • Signifies that an applicant has attained a certain level of knowledge and skills 3-5

6. Question Tell whether the following statement is true or false. Registration is an entry in an official registry or record, listing the names of persons in a certain occupation who have satisfied specific requirements. True False 3-6

7. Answer True Registration is an entry in an official registry or record, listing the names of persons in a certain occupation who have satisfied specific requirements. The list is usually made available to health care providers. 3-7

8. Registration • An entry in an official registry or record listing the names of persons in a certain occupation who have satisfied specific requirements • An applicant can add his or her name to the list. • An applicant can attain a certain level of education and pay a fee. 3-8

9. Accreditation • Official authorization or approval for conforming to a specified standard • Joint Commission accredits: • Health care practitioner education programs • Health care facilities • Managed care plans 3-9

10. Obtaining a License in Another State • Reciprocity • A state accepts a person’s valid license from another state • If a state does not grant reciprocity, the person must take the required examination to obtain a license 3-10

11. Doctor of Medicine (MD) Degree • Graduation with Bachelor’s Degree from 4-year pre-medicine course • Graduation from a 4-year medical school • In the U.S. a school accredited by the Liaison Committee on Medical Education 3-11

12. U. S. Medical Licensing Examination • Commonly called medical boards • Take part 1 after first year of medical school • Take part 2 during fourth year of medical school • Take part 3 during the first or second year of postgraduate medical training 3-12

13. National Board of Medical Examiners • Certifies physicians as NBME diplomate • Following completion of residency and medical boards • To specialize physicians must complete 2 - 6 more years training 3-13

14. Doctor of Osteopathy (DO) vs. MD • Both have 12+ years education. • Both prescribe drugs and perform surgery. • DOs focus on the musculoskeletal system and correction of joint and tissue problems. • MDs focus on allopathic medicine, using drugs/surgery for cures. 3-14

15. Reasons Physicians Specialize • Higher financial compensation • Decreased prestige for generalists • Medical training usually provided in tertiary care settings • Decreased exposure to generalist role models • Lack of attractiveness of general practices 3-15

16. Criteria for Granting State License 3-16

17. Revocation of a Physician’s License • Conviction of a felony • Unprofessional conduct • Personal or unprofessional incapacity 3-17

18. Medical Practice Acts • Define what is meant by practice of medicine in each state • Explain requirements and methods for licensure • Establish medical licensing boards • Establish ground for suspension or revocation of license • Give conditions for license renewal 3-18

19. Fraud Falsifying medical credentials Billing government agency for services not rendered Falsifying medical reports Falsely advertising to a patient secret cures or special curative powers 3-19

20. Question Tell whether the following statement is true or false. LPNs and LVNs are licensed health care team members who work under the supervision of physicians or RNs. True False 3-20

21. Answer True LPNs and LVNs are licensed health care team members who work under the supervision of physicians or RNs.They perform many of the same duties as RNs with some exceptions. 3-21

22. Respondeat Superior • Latin for “Let the master answer” • Physicians are legally responsible for their own acts of negligence and those of employees working within the scope of their employment.

23. Types of Medical Practice • Sole proprietorship • Partnership • Professional Corporation • Group practice 3-23

24. Managed Care • Corporations that pay for and deliver health care to subscribers for a set fee using a network of physicians and other health care providers • Indemnity: coverage of an insured person against personal loss of money from medical expenses 3-24

25. Cost-Containment Measures • Co-insurance • Co-payment • Deductible • Formularies • Utilization review 3-25

26. Question Tell whether the following statement is true or false. Co-insurance refers to flat fees insurance subscribers pay per service. True False 3-26

27. Answer False Co-payment refers to flat fees insurance subscribers pay per service. Co-insurance is the amount of money insurance subscribers must pay out of pocket. 3-27

28. Types of HMOs • Group model HMOs • Prepaid packages • Staff model HMOs • Individual practice association • Preferred provider organization • Physician-hospital organizations 3-28

29. Types of HMO Plans • Point-of-service plans • Allow plan members to seek health care from non-network physicians, but plan pays highest benefits for care given by PCP or referral by PCP • Open access plans • Subscriber can see any in-network health care provider 3-29

30. Legislation Affecting Health Care Patient Protection and Affordable Care Act (PPACA) Health Care and Education Reconciliation Act (HCERA) Health Insurance Portability and Accountability Act (HIPAA) Healthcare Integrity and Protection Data Bank (HIPDB) 3-30

31. Legislation Affecting Health Care National Practitioner Data Bank (NPDB) Federal False Claims Act (FFCA) Patient Bill of Rights Act 3-31

32. Telemedicine • Remote consultation with physicians or other health care professionals via telephone, closed-circuit television, fax machine, or the Internet • Cybermedicine • direct online contact between physician and patient • E-health • increasing use of the Internet as a source of consumer information about health 3-32