Purpose of healthcare credentials (3)
[pps]
? set performance standards
? pt safety
? protect healthcare workers
Licensing:
1. Who licenses the licensee?
2. Who has to be licensed
3. Who has to be licensed
4. License is good for how many states.
1. state specific by state medical boards
2. who ever performs physical pt assessments, carry out dr. orders w/o dr. on site
3. mandatory credential for physicians, chiropractors, massage therapists, nurse practitioners, etc
4. only valid in that state &
Requirements to obtain license
~Back ground check
~Proof of education/training
~Work history
~Pass "the boards" nursing NCLEX test
3 reasons for revoking or suspending license's [UEP]
~Unprofessional Conduct: pt abuse, drug/alcohol etc
~Expired license
~Physical disability (age, injury)
When is it legal for dr.'s to work w/o a state license (3)
[MR. What]
~Military, VA, public health physician (still to be licensed but not state specific)
~Research, Dr. not involved in pt care
~Waiting to become resident of the state
Endorsement
Process that allows Dr. to obtain state license based on transfer of appropriate credentials.
Reciprocity
a license earned in one state is accepted as valid in another state by prior agreement without reexamination.
*Dr.s near a border may have licenses in both states
Certification
a voluntary credentialing process where applicants that meet specific requirements may receive a certificate
Registration
One's name is listed on a register having paid a fee and/or met certain criteria within a profession.
Accreditation (mnemonics: HC puny place for mom)
Voluntary Official authorization process
� HC practitioners
� Education programs
� HC Facilities and
� Managed care plans.
The Joint Committee (TJC)
� Accredits hospitals, HMOs, dr.s offices and nursing homes � works to preserve & improve pt safety in HC
CAAHEP
Commission Accreditation Allied Health Education Programs -accredit allied health educational programs
ABHES
Accrediting Bureau of Health Education Schools - accredit allied health educational programs
Medical practice acts (roww)
State laws written to regulate medicine for U.S.:
~requirements for licensing
~outline rules, educational requirements & practice limitations
~what schools should teach
~what leads to revocation of licenses
Medical Boards
~ medical board established by each state to protect health care consumers
~state governor appoints board members (physicians and others)
~the board reviews: complaints and medical practice acts for currency
allopathic medicine
~traditional western medicine.
~ intervention of disease by drugs & surgeries
types of physicians
~Medical Dr. practices allopathic medicine
~Doctor of Osteopathy (DO) practices the premise that the body should be in alignment
***both spend 12+ years, similar education, practice medicine, prescribe drugs and perform surgery
~specialist: physician with
tertiary
care settings providing highly specialized services.
Complementary or Alternative Medicine (CAM)
problematic testing is not consistant and many mainstream medical techniques lack solid evidence
Respondeat superior
"let the master answer
� physician/employer -responsible for acts of employees-as long as acting on behalf of the physician's business - or within the scope of the employer's duty
�personnel work under the physician's license
�if unlicensed personnel act independently and not o
types of medical practices (spcag)
�sole proprietor - one physician, bears all cost and responsibility
�partnership
�corporation
�associate practice
�group practice
fee-for-service
pmt method that reimburses Dr's for individual pt visits
capitation
a set amount of money paid monthly for each covered member * cost effective
managed care
* managed care providers refer patients to other providers and facilities within the network - outside care is not covered or covered at a lesser rate
Health Maintenance Organization (HMO)
� Primarily interested in prevention and health problems � Health plan that combines coverage of health care costs and delivery of health care for a prepaid premium.
staff model
physicians are employees of the HMO and see only patients who are members
independent practice association (IPA)
A type of HMO that contracts with groups of independent physicians who practice in their own offices and receive a per-member payment (capitation) from participating HMOs to provide a full range of health services for HMO members.
Preferred Provider Organization (PPO) or (PPA)
network of independent Dr.'s hospitals, & healthcare providers that contract w/ins. to provide medical care @ discount rate to members
physician-hospital organization (PHO)
A health care plan where physicians join hospitals to provide medical care delivery system and contract for insurance with commercial carrier or HMO
point of service plan
plan allows pts to use non-network Dr's but pays the highest benefits for care with PCP referral, or PCP physician
open access
~managed care plan ~patients see any specialist within network w/o referral
Health Care Quality Improvement Act of 1986
A federal statute passed to improve the quality of medical care nationwide. One provision established the National Practitioner Data Bank.
� created by congress in response to increasing malpractice occurrences
� requires professional peer reviews in case
National Practitioner Data Bank (NPDB):
data collection program of information about health care practitioners, established by the Health Care Quality Improvement Act of 1986.
Healthcare Integrity and Protection Data Bank (HIPDB)
�instituted by HIPAA �National health care fraud abuse data collection program �reports negative actions taken against health care providers, suppliers, or practitioners.
Federal False Claims Act
a law that allows for individuals to bring civil actions on behalf of the U.S. government for false claims made to the federal government, under a provision of the law called qui tam (from Latin meaning "to bring an action for the king and for oneself")
Primary care physician (PCP)
(gatekeeper) Physician �directs patient's medical care �determines specialty care referrals.
3 branches of government
Executive, Judicial, Legislative
EXECUTIVE BRANCH
? President is the Chief Executive of the executive branch of government
� administers and enforces the laws.
� vetos congressional legislation
� nominates and appoint judges, cabinet members, Supreme Court justices, and ambassadors
JUDICIAL BRANCH
?Headed by the U.S. Supreme Court
?Federal Judges, and courts in every state.
� interprets laws
� declare laws as unconstitutional
� declare presidents actions as unconstitutional
LEGISLATIVE BRANCH
? Congress -(two houses) Senate and House of Representatives
� Impeach president and remove from office
� Override presidents veto
� Accept or reject judicial nominations
What are the duties of Congress
write, debate and pass bills which are then passed on to the president for approval.
What are the powers of Congress
? Make laws controlling TRADE
? Makes laws about taxes and borrowing money.
? Approve printing of money
? Declaring war
House of Representatives
? based on state populations
? 435 seats
? 2 year terms
? Introduce legislation that force people to pay taxes
? Decision to pursue impeachment.
Senate
? 2 members from each state
? 6 year term
? Approve/Disapprove any treaties the president makes
? Approve/Disapprove any people the president recommends for jobs (cabinet officers, Supreme Court justices, and ambassadors.
The U.S. Supreme Court
� Appointed by the Chief Executive of the executive branch of government,
� responsible for administering the law �heads the judicial branch of government
What is the checks and balances system
Constitutional system that keeps any one branch from assuming too much power over the other branches
? Executive enforces laws,
? Legislative writes laws
?Judicial interprets laws
What are the 4 types of laws based on their origin mnemonics: C Cas
? CONSTITUTIONAL LAW: law derived constitutional rights
* ? CASE LAW: based on legal precedent, applied to future cases
? ADMINISTRATIVE LAW: laws that govern administration and define power distribution
* ? STATUTORY LAW: laws based on bills passed by Co
common law
The body of unwritten law developed in England, primarily from judicial decisions based on custom and tradition.
State governments 3 branches?
? Executive: the governor is the head of executive branch
? Legislative:
? Judicial:
legal precedents
prior case decisions made under similar circumstances
substantive law
? laws that determine rules for one person suing of another.
procedural law
Legal procedures used to enforce substantive law. ? Example: law enforcement officer must read a prisoner his/her rights
criminal law
Law that involves crimes against the state or federal government.
? murder, burglary, robbery, arson, rape, practicing medicine without a license.
felony
� Most serious crime. � An offense punishable by death or by imprisonment in a state or federal prison for more than one year.
misdemeanor
A less serious crime punishable by fine, community service, imprisonment in a facility other than a prison for less than one year.
Tort
a civil wrong committed against a person or property, excluding breach of contract.
? Example: one person may sue another for a specific reason.
Intentional torts
� assault, battery, defamation of character, false imprisonment, fraud, invasion of privacy
�moving one's fist in threatening way
Unintentional tort
negligence (frequent allegation against healthcare workers) - civil liability only exists if the act has been judicially shown to be wrongful
Civil law
� Non-criminal law.
� Person sues another person, business or government for a wrongful act or negligences
� Not necessary to prove guilt beyond a reasonable doubt.
federal law governing collections in the medical office
...
associate practice
several sole proprietors work under one roof but remain individually liable
corporation
several individual doctors form a company which act as its own entity
cybermedicine
a form of telemedicine that involves direct contact between patients and physicians over the internet, usually for a fee.
E-health
Term used for the use of the internet as a source of consumer information about health and medicine
group practice
can be a partnership or corporation, may include several specialties
Indemnity
traditional form of health insurance that covers the insured against a potential loss of money from medical expenses resulting from an illness or accident.
licensure
mandatory credentialing process established by law, usually at the state level, that grants the right to practice certain skills and endeavors.
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.
Name three health professions that are licensed
MD, RN, LVN, DO and Therapist
Under which circumstances does a dr not need a license to practice medicine (no mr.)
* Not treating pt's (research)
* Out of state, waiting for state residency
* Military
* Responding to emergency
What are four acts that may lead to license revocation for physician (fuca)
� fraud
� unprofessional conduct(dealing drugs, murder, practicing under the influence of alcohol or drugs
� convicted of a felony
� abusing pt's
Why must a physician be on site to supervise unlicensed allied health professionals
liability
what is the purpose of CAAHEP
ACCREDITATION OF HEALTHCARE PROGRAMS
Name three examples of fraud in healthcare
�Upcoding
�Making up fake pt's & billing
�false billing to ins. for clinic supplies
�prescribing unnecessary treatments
�self referring pt
Which branch has exclusive authority to declare war on another country
Legislative Branch
Which chamber of Congress has exclusive authority to declare war on another country:
Senate
Which law started with common law
Case Law
Two laws that are most likely to affect health care providers
Criminal & Civil
Court judgements in lawsuits against health care practitioners most often include what as a penalty
Payment of a sum of money to the injured party, death or imprisonment in a state or federal prison for more than a year.
The highest tier of federal courts consists of
State Supreme Court
lawsuit brought by a patient against a health care practitioner would be heard first what court
Lower court
The tort most likely to affect a healthcare provider is
Unintentional
4 elements of a legally, valid contract (aclc)
?Agreement-one party offers something, the other accepts it
? Consideration-something valuable is to be exchanged such as services for pmt.
?Legal Subject Matter-must be legally valid (physician treating the pt must be licensed, or contract is invalid.)
?
3 federal laws governing collections in the medical office
? Third party payer contract
?Fair Debt Collection Practices Act (FDCPA)
?Statues of frauds
Name 2 HC professions, other than dr's that dx and/or tx pt's.
� Nurse Practitioner's
� Physicians Assistants
Profession that requires no license
CMA
Business and Professions Code
Laws governing the practice of medicine and other allied health care professions regulated by the Medical Board
State Medical Boards
Review State Medical Boards
criminal offense
Crime against the state
Governor
Chief executor of state
Negligence
Failure to recognize consequences, disregarding consequences
implied contract
pt conduct of going to see dr.
expressed contract
Two parties discuss and agree on terms of a transaction
Third party contract
When another person offers to pay pt's bills
Termination letter
letter that should be sent when pt is dismissed from practice