Ch. 3 Ethics

Licensure

A mandatory credentialing process established by law, usually at the state level, that grants the right to practice certain skills and endeavors.

Licensure is a mandatory credentialing process established by

law, usually at the state level.Licenses to practice are required in every state for all physicians and nurses and for many other health care practitioners as well.

certification

A voluntary credentialing process whereby applicants who meet specific requirements may receive a certificate.

Certification is a voluntary credentialing process, usually

usually national in scope, and is most often sponsored by a nongovernmental, private-sector group. Certification by a professional organization, usually through an examination, signifies that an applicant has attained a certain level of knowledge and skil

Registration

A credentialing procedure whereby one's name is listed on a register as having paid a fee and/or met certain criteria within a profession.

Registration is an entry in

an official registry or record, listing the names of persons in a certain occupation who have satisfied specific requirements

Accreditation

Official authorization or approval for conforming to a specified standard, for health care education programs, health care facilities, and managed care plans.

For example, if the school where you are enrolled is accredited by a recognized regional or national accrediting agency, advantages for you include:

Assurance of high-quality standards at your school.nAn opportunity for you to participate in federal and state financial aid programs.
Better chance credits at your present school will be accepted at another institution if you transfer schools or attend g

medical practice acts

State laws written for the express purpose of governing the practice of medicine.

In all 50 states, medical practice acts have been established by statute to govern the practice of medicine. Primary mandates of medical practice acts are to:

Define what is meant by "practice of medicine" in each state. Explain requirements and methods for licensure.nProvide for the establishment of medical licensing boards.
Establish grounds for suspension or revocation of license. Give conditions for license

Medical practice acts can be found in each state's code, which consists of laws for that state. Copies of state codes are available in most

public libraries, in some university libraries, and on the Internet.

Each state's medical practice acts also define unprofessional conduct for medical professionals. Laws vary from state to state, but examples of unprofessional conduct include:

Physical abuse of a patient.
Inadequate record keeping.
Failure recognize or act on common symptoms.
prescription drugs in excessive amounts or without legitimate reason.
Impaired ability to practice due to addiction or physical or mental illness.
Failure

medical practice acts: Minor disagreements and poor customer service do?

do not fall under the heading of misconduct.

medical boards

Bodies established by the authority of each state's medical practice acts for the purpose of protecting the health, safety, and welfare of healthcare consumers through proper licensing and regulation of physicians and other health care practitioners.

Each state's medical practice acts also mandate the establishment of medical boards, whose purpose is to protect?

the health, safety, and welfare of healthcare consumers through proper licensing and regulation of physicians and, in some jurisdictions, other health care practitioners. Board membership is composed of physicians and others who are, in most cases, appoin

Funding for state medical boards comes from?

licensing and registration fees. Most boards include an executive officer, attorneys, and investigators. Some legal services may be provided by the state's office of the attorney general.

each state medical board ensures that all health care practitioners who work in areas provide:

proof of education and training.mwork history.
Pass an examination designed to assess their knowledge and their ability to apply that knowledge and other concepts and principles important to ensure safe and effective patient care.Reveal information about

A physician is considered guilty of fraud if "intent to deceive" can be shown as unprofessional conduct. Acts generally classified as fraud include:

Billing a governmental agency for services not rendered.
Falsifying medical reports.
Falsely advertising or misrepresenting to a patient "secret cures" or special powers to cure an ailment.

sole proprietorship

A form of medical practice management in which a physician practices alone, assuming all benefits and liabilities for the business.

group practice

A medical management system in which three or more licensed physicians share the collective income, expenses, facilities, equipment, records, and personnel for the business

Consolidation arrangements may take the form of group practices, where ?

three or more physicians engage full time in providing health care services. They share the collective income of the practice, as well as expenses, facilities, equipment, patient records, and personnel necessary for running the business.

associate practice

A medical management system in which two or more physicians share office space and employees but practice individually.

Associate Practice

Two or more physicians decide to practice individually but agree to share office space and employees. This arrangement allows a sharing of expenses, but usually not a sharing of profits or liability.

partnership

A form of medical practice management system whereby two or more parties practice together under a written agreement specifying the rights, obligations, and responsibilities of each partner.

Partnership: Two or more parties practice together under a written agreement specifying

rights, obligations, and responsibilities of each partner. Advantages of partnerships include sharing the workload and expenses, and pooling profits and assets. disadvantage each partner has equal liability for acts, conduct, losses, and deficits of the p

professional corporation

A body formed and authorized by law to act as a single person. constituted by one or more persons and legally endowed with various rights and duties. State law governs corporations

Physicians who form corporations are

shareholders and employees of the organization.financial and tax advantages to forming a corporation, and fringe benefits to employees may be more generous. have limited liability in case lawsuits are filed.

managed care

A system in which financing, administration, and delivery of health care are combined to provide medical services to subscribers for a prepaid fee.

Managed care organizations are corporations that ?

pay for and deliver healthcare to subscribers for a set fee using a network of physicians and other health care providers.

Coinsurance

refers to the amount of money insurance plan members must pay out of pocket, after the insurance plan pays its share. example, plan agrees pay 80 percent of the cost for a surgical procedure, and subscriber pays remaining 20 percent.

Deductible

amounts are specified by the insurance plan for each subscriber. example deductible for a single subscriber $500 a calendar year. the plan does not begin to pay benefits until the $500 deductible has been satisfied.

Copayment fees

flat fees that insurance plan subscribers pay for certain medical services. example subscriber might be required to make a $20 copayment for each visit to a physician office.

Formularies

are a plan's list of approved prescription medications for which it will reimburse subscribers.

Utilization review

method used by a health plan to measure the amount and appropriateness of health services used by its members.

health maintenance organization (HMO)

A health plan that combines coverage of health care costs and delivery of health care for a specific payment.. Under HMO plans, all health services are delivered and paid for through one organization.

Group model HMOs contract with ?

independent groups of physicians to provide coordinated care for large numbers of HMO patients for a fixed, per-member fee. include prepaid group practices. Physicians in PGPs are salaried employees.

Staff model HMOs employ salaried physicians and other allied health professionals who provide care solely for members of one HMO. Subscribers ?

to staff model HMOs can often see their doctors, get laboratory tests and X-rays, prescriptions filled, and order eyeglasses or contact lenses all in one location.

An individual or independent practice association (IPA)

type of HMO contracts groups of physicians who practice in their own offices and receive a per-member payment or capitation from participating HMOs to provide a full range of health services for members. see patients outside the contracting HMO gives them

preferred provider organization (PPO) Also called preferred provider association (PPA).

A network of independent physicians, hospitals, and other health care providers for set fees. Subscribers may choose their primary health provider from an approved list for discount rate. pay higher out-of-pocket costs for care provided outside the PPO gr

primary care physician (PCP)

The physician responsible for directing all of a patient's medical care and determining whether the patient should be referred for specialty care. aka Gatekeeper or primary care plan.

Open access plan

Under open access plans, subscribers may see any in-network health care provider without a referral.

Patient Protection and Affordable Care Act (PPACA) usually abbreviated ACA

A federal law enacted in 2010 to expand health insurance coverage and otherwise regulate the health insurance industry

As a provision of the ACA, health care insurers were encouraged to unite with health care providers to form

accountable care organizations (ACOs). The accountable care model emphasized preventive care, health care team coordination, electronic health records, treatment based on proof, and day or night access.

Health Care Education and Reconciliation Act (HCERA)

Also enacted in 2010, a federal law that added to regulations imposed on the insurance industry by PPACA.

Health Insurance Portability and Accountability Act (HIPAA) of 1996

A federal statute that helps workers keep continuous health insurance coverage for themselves and their dependents when they change jobs, protects confidential medical information from unauthorized disclosure or use, and helps curb the rising cost of frau

HIPAA primary objectives of the law were to: Improve efficiency and effectiveness of healthcare industry by:

Accelerating billing processes. reduce paperwork. healthcare billing fraud. tracking health information.
Improving accuracy and reliability of shared data.
Increasing access to computer networks within health care facilities.
Help employees keep health in

HIPAA also created the Healthcare Integrity and Protection Data Bank (HIPDB)

HIPDB with the National Practitioner Data Bank. HIPDB is a national health care fraud and abuse data collection program for the reporting and disclosure of certain adverse actions taken against health care providers, suppliers, or practitioners.

National Practitioner Data Bank (NPDB)

Information that must be reported to the NPDB includes medical malpractice payments, adverse licensure actions, adverse clinical privilege actions, and adverse professional society membership actions. a resource to assist state licensing boards, hospitals

2010 merged,
HIPDB and NPDB because of what?

Patient Protection and Affordable Care Act or ACA. Data from the combined HIPDB and the NPDB are available to federal and state government agencies and to health plans, but are not available to the general public.

managed care

A system in which financing, administration, and delivery of health care are combined to provide medical services to subscribers for a prepaid fee.