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Terms and Chapter Stacks

Licensure Mandatory credentialing process established by law; usually state level. Req. in all states for Phys, RN etc..
Certification Voluntary credentialing, usually national scope. Sponsored by non gov, private sectors. Shows attained specific skills and knowledge.
Registration Entry in an official registry or record. Lists names of people in certain occupations who satisfied specific requirements. 2/ Edu or reg. fee
Accreditation Assurance of high quality standards, based on latest research and professional Practice. Opportunity to participate in fed/state fin aid programs. Better chance credits earned are accepted elsewhere who wish to graduate.
CAAHEP Commission of Accreditation of Allied Health Education Programs
ABHES Accrediting Bureau of Health Education Schools
HMO Health Maintenance Organizations
PPO Preferred Provider Organizations
TJC The Joint Commission - accredits Health care orgs. meeting certain standards: General, Psy., Peds, Rehab Hospitals. Critical Access Hospitals. Health Care Networks (HMOs/POs), Integrated delivery networks, Managed Behavioral Health Care Orgs. Home Care
TJC Cont. Home care orgs: providing home health care services, personal care & support services, Home infusion and Pharma services, med. equip. services and hospice.
NCQA National Committee for Quality Assurance - independent, nonprofit org, evals and reports on quality of nation's managed care orgs. NCQA Evaluates managed care programs in 3 ways...
NCQA - evaluations managed health care programs in 3 ways: on site reviews of key clinical and admin processes. Via healthcare Effectiveness Data and Information Set (HEDIS) (data used to measure performance in areas like immunizations and mammo screen rates. Via member satisfaction surveys.
NCQA Programs: Voluntary. To earn and maintain TJC accreditation: Org must undergo onsite survey by a TJC survey team at least every 3 years. Labs, every 2 yrs.
Reciprocity State Lic. Authority will accept valid license from another state as proof of competency, without re-exam.
MD - Doctor Of Medicine Degree MD Degree: Must graduate with a BA from a 4 yr, premed course (science concentration). Graduate from a 4 year med school in the U.S, an accredited school by the Liaison Committee on Medical Education. Upon graduation = MD degree
MD - Doctor of Medicine Degree (cont) After awarded MD, Must pass USMLE - U.S Med Lic. Examination "medical boards". Part 1 - after first year of med school Part 2 exam during 4th year of med school. Part 3 exam: during first or 2nd year of post-grad med training.
MD - Doctor of Medicine Degree (cont) Next: Completion of a residency (practical post grad training in a hospital). (Internship) To specialize, 2-6 yrs of residency in chosen specialty, apply to ABMS American Board of Medical Specialists Exam.
MD's and DO's spend 12 yrs or more training to become physicians. Both Osteopathic and med Dr.s prescribe drugs/perform surgery. Osteopathic Docs are trained for Musculo-joint/tissue.
Allopathic Medicine Different Suffering. Intervention in form of drugs & or surgery to alleviate symptoms.
Endorsement process by which a license may be awarded based on indiv. credentials, judged to meet Lic. Requirements in new state of residence
Medical Practice Acts Established by statute to govern the practice of medicine.
5 Primary mandates of MPA's: 1 define "practice of medicine" in each state 2 Explain Req.'s & methods for Lic. 3 Provide for establishment of Med Lic boards. 4 Establish grounds for Suspension/Revocation of Lic 5. Give conditions for Lic Renewal
Purpose of Medical Boards to protect health, safety and welfare of Health care consumers via proper Lic and regulation of physicians and other HCP's
unprofessional conduct include: Physical abuse of a patient. Inadequate record keeping. Failure to recognize or act on common symptoms. The prescription of drugs in excessive amounts or without legitimate reason.
unprofessional conduct include: Impaired ability to practice due to addiction or physical or mental illness. Failure to meet continuing education requirements. The performance of duties beyond the scope of a license. Dishonesty
unprofessional conduct include: Conviction of a felony. The delegation of the practice of medicine to an unlicensed individual.
Acts of Fraud Falsifying medical diplomas, applications for licenses, licenses, or other credentials. Billing a governmental agency for services not rendered.
Acts of Fraud Falsifying medical reports. Falsely advertising or misrepresenting to a patient “secret cures” or special powers to cure an ailment.
Sole Propriertorship Physician practices alone, assumes all responsibility and liability for services
Group Practice 3 or more physicians engage full time providing services, share collective income, expenses, facilities, equipment, pt. records, personnel. Same specialty. Ex. Urology & Associates
Associate Practice 2 or more decide to practice individually to share office space and employees. sharing of expenses, not sharing profit or liability
Partnership 2 or more practice under written agreement specifying rights, obligations, responsibilities of each partner.
Professional Corporation body formed and authorized by law to act as a single person and legally endowed with various rights and duties.
Managed Care corporations that pay for and deliver health care to subscribers for a set fee using a network of physicians and HC providers
Capitation a set advance pyt. made to providers, based on calculated cost of med care of a specific population of subscribers
Coinsurance amount of $ ins. plan members must pay out of pocket, after ins. pays its share. (ex. 80/20)
Copayment Fees Flat fees ins. plan holders pay for certain med services
Deductible Amts. set by ins. plan for each member. (Plan doesn't pay until deductible is met)
Utilization Review Method used by health plan to measure amount and appropriateness of services used by its members
HMO Health Maintenance Organizations 3 General Types of HMOSs: Group model, staff model, indiv./independent practice associations (IPAs)
Group Model HMO contract with independent groups of phys. to provided coordinated care for large # of HMO pt.'s for Fixed, per member fee. Includes prepaid group practices PGPs
PGPs Prepaid Group Practices - salaried employees of the HMO, share profits at end of year
IPA Individual (independent) Practice Association - Assoc. of phys. hospitals, other HC providers contracts with an HMO to provide med serv to subscribers. IA may see pt.'s outside of the contracting HMO. Per member pymt or capitation from partic. HMO
PPO Preferred Provider Orgs/Assoc. PPAs. Managed care plan contracted with network of docs, hospitals, other HCP's. Provide serv for set fees. May choose PCP from approved list. Higher out of pocket costs outside of the PPO
PHO Physician Hospital Orgs - Managed health care includes Phys., hospitals, surgery centers, nursing home, labs who contract with 1 or more HMOS, ins. plans or directly with employers to provide health care serv.
PCP Primary Care Physician - Gatekeeper phys. Directs all pt.'s med care, referrals or other HCPs. Point of Service Plan (POS) allow to see outside network phys., plan pays highest benefits when given by the PCP or via referral. Open Access Plan - in network
POS )POS) point of Service plans allow to see outside network phys., plan pays highest benefits when given by the PCP or via referral. Open Access Plan - in network w/o referral
PCMH Org offers accreditation to qualifying primary care practices implementing PCMH Patient Centered Medical Home. Helps pt.'s find those practices
PPACA or ACA Patient Protection and Affordable Care Act Obama - 2010 provisions: Temp. high risk ins. pool, preexisting conditions, the HCERA health care edu and reconciliation act revised 2 acts of mandated major changes
ISSUE: Temporary high-risk insurance pool EFFECT: Creates a national pool to provide health coverage for individuals with preexisting conditions who have been uninsured for six months.
ISSUE: Preexisting Conditions Prevents insurance companies from denying coverage to children with preexisting medical conditions.
ACO Accountable Care Orgs - emphasized preventative care, team coordination, elect. records, Tx based on proof, day/night access. ACOs that meet quality standards are rewarded
HIPPA Health Insurance Portability Accountability Act of 1996 - TO improve efficiency and effectiveness of health care industry by: 1 accelerate billing, reduction of paperwork 2 reduce billing fraud 3 improved accuracy and reliability of shared data
HIPPA (cont) 4 Increased access to computer networks in facilities 5 Help employees keep health ins. when transfer to another job 6 Protect confidential med. info that ID's pt.'s from unauthorized disclosure/use
Telemedicine remote consult with docs or other HCP's via phone, internet, cells, closed circuit Tv, fax. Provides Services of: Primary care and specialist referrals. Remote pt. monitoring (heart monitors/holsters/glucose levels etc)
Created by: MCasler
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