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Chapter 2 - Working in Health Care McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved 2-1
LEARNING OUTCOMES Define licensure, certification, registration, and accreditation. Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. Define four types of medical practice management systems. Discuss two federal acts that prohibit fraud and abuse in health care billing. Define three types of managed care plans. Define telemedicine, cybermedicine, and e-health and discuss their roles in todays health care environment. 2-2 McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
Health care professionals are licensed and/or certified. Organizations such as hospitals, ambulatory care centers, nursing homes, etc. are accredited. They also must have a license to operate their business. Educational programs for health care professionals are usually accredited, and usually only graduates of accredited programs are allowed to sit for either licensure or certification. 2-3 McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
Licensure Mandatory credentialing process Required for a variety of health care practitioners Nurses Physicians Dentists Pharmacists PAs, ARNPs Done by state Certification Voluntary credentialing process Usually sponsored by a professional association Is national in scope, often requiring documentation of education 2-4 McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
Registration is usually a voluntary process where one pays a fee and is put on a list. Some registration lists do NOT require additional educational requirements. 2-5 McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
Joint Commission on Accreditation of Health Care Organizations Accredits hospitals, health care networks, home care organizations, nursing homes, assisted living facilities, outpatient surgery centers, lab, and other health care facilities National Commission for Quality Assurance Accredits managed care plans 2-6 M cGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
Some allied health care educational programs are accredited by the Commission on Accreditation of Allied Health Education Program (CAAHEP). Some allied health care educational programs are accredited by specific organizations such as the National League of Nursing (NLN) for registered nursing programs. Health care education programs are national accreditation; some states may have additional requirements. 2-7 McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
Many states will accept a persons valid license from another statethis is reciprocity. Those states that will not allow reciprocity require the individual to take an examination to be licensed in their state. 2-8 McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
All states have a medical practice act Defines what practice of medicine is Explains requirements for licensure Provides for licensing board Establishes grounds for suspension or revocation of license Provides conditions for license renewal 2-9 McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
Designed to protect the health, safety, and welfare of individuals Major role is to ensure proper licensing and regulation of physicians Defines unprofessional conduct In some states, is responsible for licensure of other health care professionals 2-10 McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
All allied health professions are a part of the health care team. Each allied health profession has its own education, certification, registration or licensing requirement. Some states have additional requirements beyond national requirements. McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved 2-11
Physicians are licensed by individual states to practice medicine. The physician may have licenses in more than one state. Physicians also must have a permit from the Drug Enforcement Administration if they prescribe, dispense or administer controlled substances McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
Latin for Let the master answer. Physicians are responsible for the actions of employees working within their scope of employment. Is based on the law of agency which will be discussed in Chapter 3. McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved 2-13
Sole Proprietorship Single physician Partnership Two or more physicians practicing together, but not incorporated Professional Corporation May be one or many physicians who have formed a corporation for tax and liability purposes Group Practice Three or more physicians who have formed either a partnership or corporation 2-14 McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
Health Maintenance Organizations (HMOs) Different models of HMOs in different market areas Patients must use the identified HMO services Preferred Provider Organizations (PPOs) Network of doctors and hospitals Patients pay higher out of pocket fees if they use out of network providers Physician-Hospital Organizations (PHOs) Network of doctors and hospitals that contract with PPOs and HMOs or employers Patients pay higher out of pocket fees if they use out of network providers 2-15 McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
Passed in 1986 Designed to encourage peer review Established the National Practitioner Data Bank (NPDB) NPDB used by hospitals and other health care organizations NPDB information is NOT available to the public 2-16 McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
Enacted in 1996 with a three major objectives Improve efficiency and effectiveness of the health care industry Help employees keep health insurance coverage when transferring to another job Protect confidential medical information from unauthorized disclosures (see Chapter 7) McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved 2-17
Enacted in 1986 Also known as the Whistle Blowers Act Allows individuals to bring suit on behalf of the U.S. government These individuals share in court awarded damages Has been used successfully in Medicare fraud cases McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved 2-18
Telemedicine originally meant consultations via telephone or closed circuit TV The Internet has created Cybermedicine-online contact between doctor and patient E-health-use of the Internet as a source of consumer information Consumers must evaluate websites for reliability 2-19 McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
Would you seek medical care from a physician online? Why or why not? Have you ever asked a physician or the office staff to waive the co-payment because you are a fellow health care provider? How would you handle that request from a fellow health care worker? Have you seen advertisements for medical care services that promised more than they could deliver? 2-21 McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved
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