Review of Ch 1 thru 3

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Review for Exam 1

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MAS 115 Medical Office Administration:

MAS 115 Medical Office Administration Chapters 1 ~ 3 Review for Exam

Some advantages of Managed Care include::

Some advantages of Managed Care include: 100% coverage of approved treatment with very little out-of-pocket expense People are more likely to get preventative care since their insurance is pre-paid

Capitation is::

Capitation is: A fee ‘per head,’ usually per month, paid to the physician by a managed care insurance company

Which type of medical practice has the advantage of shared liability?:

Which type of medical practice has the advantage of shared liability? Solo practice Associate practice Group practice

They are two types of “permission” from patients to share PHI:

They are two types of “permission” from patients to share PHI Consent ~ for routine transactions Authorization ~ for special transactions

Examples of bioethical issues today include::

Examples of bioethical issues today include: IVF and other reproductive technologies, stem cell research, cloning, surrogacy, euthanasia

What’s malpractice?:

What’s malpractice? Literally “bad practice” It means carelessness or negligence of a professional

Bonding is:

Bonding is Insurance against embezzlement

Can you name six ways an administrative medical assistant can protect their patient’s PHI?:

Can you name six ways an administrative medical assistant can protect their patient’s PHI?

Name some good characteristics that demonstrate a professional attitude::

Name some good characteristics that demonstrate a professional attitude: Initiative Honesty Respectful Dependable Decisive Accurate Confidential Ethical

Credentialing is:

Credentialing is Review of the physician’s curriculum vitae (resume); checking up on hospital, practice history and peer references; and often includes an oral interview

Some examples of Managed Care Organizations include::

Some examples of Managed Care Organizations include: HMO PPO IPA EPO POS

HIPAA is:

HIPAA is The Health Insurance Portability & Accountability Act Regulates the rules regarding privacy of protected health information (PHI)

Medical Practice Acts are:

Medical Practice Acts are State acts that regulate the requirements for obtaining a medical license Designed to protect the public from “quackery”

Tort is:

Tort is A tort is when one person causes injury to another person

Important interpersonal skills to have are::

Important interpersonal skills to have are: Observing Showing interest, concern Watching your tone of voice Empathy Initiative Teamwork LISTENING!

Three steps in coping with stress include::

Three steps in coping with stress include: 1) Identify the cause of stress 2) Evaluate the situation ~ what can you do about it? 3) Confront the problem ~ Make a decision and do it!

Five stages of dying (in order) are::

Five stages of dying (in order) are: Denial Anger Bargaining Depression Acceptance

Hospice is:

Hospice is Medical care and support for patients and families during terminal illness

HIPAA’s security rule covers::

HIPAA’s security rule covers: Physical and technical safeguards Policies, procedures, documentation requirements Risk analysis and management Administrative safeguards

Who “owns” the medical record?:

Who “owns” the medical record? The physician (or the health care organization itself)

Respondeat Superior means::

Respondeat Superior means: Literally “let the master answer” Figuratively it means that an employer can be held liable for the actions of its employees

You do NOT need authorization to share PHI under these conditions::

You do NOT need authorization to share PHI under these conditions: In emergencies When mandated by the State to report communicable diseases or concerning conditions When subpoenaed by a court of law Federally-funded programs automatically have authorization to receive certain PHI

An authorization is:

An authorization is “Special” permission from a patient to share certain PHI with certain people regarding a certain timeframe

A Consent is::

A Consent is: “Routine” permission from a patient to share information regarding treatment, payment or other routine health care operations

What’s a Compliance Officer?:

What’s a Compliance Officer? A person who oversees and monitors an organization’s HIPAA compliance plan

Misfeasance means:

Misfeasance means Lawful or proper treatment but done incorrectly

Who oversees the Medical Practice Act?:

Who oversees the Medical Practice Act? Each State Board of Medical Examiners oversees its own State Medical Practice Act

HIPAA’s privacy rule defines patient’s rights which include::

HIPAA’s privacy rule defines patient’s rights which include: Patient’s have a right to receive notice about how an organization is sharing their PHI They have a right to access their own records They have a right to ask for amendment to their own records They have a right to ask a health care organization for an “accounting” – when and to whom were their records released? They have a right to restrict disclosures of information

What’s the Good Samaritan Law?:

What’s the Good Samaritan Law? State laws (they vary) which protect off-duty health care workers and others from liability when responding to emergencies It’s intended to ENcourage health care workers to help…without fear of being sued No duty = no contract and no 4D’s of negligence HOWEVER ~ actions must be considered “prudent,” not reckless; nor can doctor “charge a fee” for service

Nonfeasance means:

Nonfeasance means Failure to treat when there was a duty to do so

Types of Contracts::

Types of Contracts: Expressed Contract ~ Written or verbal agreement Implied Contract ~ An agreement deduced from the situation (emergencies) or from the patient’s behavior NOTE: No Contract exists during a “Good Samaritan” action

What are some alternatives to litigation?:

What are some alternatives to litigation? Screening panel A physician review panel; advisory but cannot bar litigation Arbitration Agreed upon before treatment; in some States this can be a binding decision No-fault insurance “Injured person is compensated without regard to fault” (p. 78)

What are some “defenses” the physician may use if sued?:

What are some “defenses” the physician may use if sued? Contributory negligence ~ the patient was in some way responsible for his or her own injuries (fully or partially) Assumption of risk ~ the patient was informed of the risks of treatment but chose to consent anyway Statute of Limitations ~ the time limit to take legal actions has passed/expired

Malfeasance means:

Malfeasance means Improper or unlawful treatment

The 4D’s:

The 4D’s Are: Duty Dereliction (of duty) Direct Cause Damages All four are necessary to prove negligence

Some ways you can reduce litigation for your office/employer::

Some ways you can reduce litigation for your office/employer: Obey the LAW! Work within the scope of your training and be careful Don’t ( assume and then ) admit fault Don’t make promises Don’t practice medicine without a license! Keep timely, accurate records AND ~ LISTEN and COMMUNICATE

Examples of intentional torts include::

Examples of intentional torts include: Assault & Battery* Invasion of Privacy* Defamation of Character Libel or Slander False Imprisonment* Fraud *MY NOTE: Some of these can be “negligent” torts as well – depends on “intent” of the accused

Examples of negligent (or UNintentional) torts might include::

Examples of negligent (or UNintentional) torts might include: Accidentally administering incorrect dose Accidentally faxing PHI to wrong number Accidentally documenting information in the wrong chart… Negligence occurs when we do not “behave in the way a prudent person who is similarly educated and trained would behave under comparable circumstances.” MY NOTE: In health care, most lawsuits are regarding UNintentional torts

What’s “Criminal Negligence?”:

What’s “Criminal Negligence?” Reckless disregard for, or indifference to, the welfare of a patient

What kind of comments could be perceived as “Promise to cure?”:

What kind of comments could be perceived as “Promise to cure?” “You’ll be just fine…” “Dr. Smith will fix you right up…”

What is “stress?”:

What is “stress?” Physical and psychological tension, caused by both “good” and “bad” events in our lives

It’s when a physician is not available when the patient seeks help:

It’s when a physician is not available when the patient seeks help Abandonment Today, doctors must be careful to communicate with patients – terminate the contract properly, have ‘coverage’ available for patients when they are ill or on vacation, etc.

Reasons a physician might terminate a contract with patient::

Reasons a physician might terminate a contract with patient: Failure to pay for appointments Failure to appear for appointments Failure to follow medical advice

How should a patient be informed their contract with physician is terminated? :

How should a patient be informed their contract with physician is terminated? In writing Mailed certified with return receipt Letter should state reason, and allow enough time for patient to find new doc Copy of letter and signed receipt should be filed in patient’s chart as “proof” of proper termination PURPOSE: To avoid charge of abandonment

What’s an advance directive?:

What’s an advance directive? Legal form detailing the desires of the patient for procedures to either be performed or withheld when death is imminent

Examples of advance directives::

Examples of advance directives: Living Will Health Care Power of Attorney Medical Directive Values History Form Health Care Proxy DNR (Do Not Resuscitate) Donor/Anatomical Gift Form

Some “advantages” for the patient with Traditional Care insurance (versus Managed Care): :

Some “advantages” for the patient with Traditional Care insurance (versus Managed Care): Patients feel they have more choice – they can see any doctor, any time, as often as they want (no ‘network’) No pre-authorization is required so there are no delays in treatment, referrals, getting medications

What is “Informed Consent”:

What is “Informed Consent” Remember it has two parts – “Informed” and “Consent” Informed ~ doctor explains risks, benefits, alternatives of recommended treatment and answers any questions Consent ~ patient agrees to treatment after being informed, often “signing” a formal consent agreement

Special rules about “Minors”:

Special rules about “Minors” States have varying laws about minors Emancipated Minors can personally consent to treatment “Mature minor” is usually over 14 years of age and can often consent to medical/surgical treatment without parental consent Reproductive Health issues: Abortion, pregnant unmarried minors – rules vary by State

Sources of stress include::

Sources of stress include: Good Marriage Birth of a baby Better Job Moving Bad Divorce Death Loss of job Health issues

What’s a gatekeeper?:

What’s a gatekeeper? A primary care doctor who oversees the patient’s plan of care This position is designed to help Managed Care control costs by scrutinizing referrals, pre-authorizing tests or drugs, etc.

Subpoena is:

Subpoena is Court order to appear Subpoena duces tecum is Court order to appear with records

PHI stands for:

PHI stands for Protected Health Information It includes personal identification and patient’s health information

Some reasons doctors are more likely to be sued today::

Some reasons doctors are more likely to be sued today: Well educated public expects the best care regardless of ability to pay; when they don’t get it, they may sue Different “relationship” with doctors today; not held on a pedestal; more like “equal partners” in health care. Patients more like to question, compare (and sue) doctor Bioethical issues generate lawsuits – new, untested legal ground = lawsuits Managed care can cause delays in approvals, testing, diagnosis = lawsuits

What’s the difference between an “authorization” and a “pre-authorization?:

What’s the difference between an “authorization” and a “pre-authorization? An authorization is special patient permission to share certain PHI A pre-authorization is a request sent to managed care insurance for the purpose of gaining their agreement to pay for certain services, testing, drugs, etc. If they “approve” they will pay; if they do not approve, they will not pay.

What’s the difference between a consent and an informed consent?:

What’s the difference between a consent and an informed consent? Consent is permission from a patient to share routine health care information with insurance companies, other people involved in their care Informed consent is when a provider ‘informs’ patient of risks, benefits, alternatives to treatment, and then the patient gives (usually written) consent for the treatment as described

Some reasons for the rise in health care costs today include::

Some reasons for the rise in health care costs today include: Increased cost of a medical education Increased lawsuits cause increase in medical malpractice insurance Longer life expectancy = more people with chronic health issues = increased costs Increased technology = increased specialization = higher cost for personnel Docs over-prescribing, over-testing to reduce liability = wasteful = higher costs

“Think with empathy, act through ___________________”?:

“Think with empathy, act through ___________________”? SERVICE!

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