Working in health care chapter 3 Lesson 3.1

lesson 3.1

Define licensure, certification, registration, and accreditation

Lesson 3.2

Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board.

Lesson 3.3

Discuss the changing configuration of health care management

Lesson 3.5

Discuss among the different types of managed cared health plans

Lesson 3.6

Discuss the impact of telemedicine and social media on the health care workplace

Key terms


Accountable Care Organization (ACO)

A health care payment and delivery model that could reward doctors and hospitals for controlling costs and improving patient outcomes by allowing them to keep a portion of what they save if standards of quality are met.


official authorization or approval for conforming to a specified standard.


Literally, "different suffering", referring to the medical philosophy that dictates training physicians to intervene in the disease process, through the use of drugs and surgery.

Associate Practice

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


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

Group Practice

A medical management system in which group of three or more licensed physicians share their collective income, expenses, facilities, equipment, records, and personnel.

Health Care Education and Reconciliation Act (HCERA)

Enacted in 2010, a federal law that added to regulations imposed on the insurance industry by the Patient Protection and Affordable Care Act.

Health Insurance Portability and Accountability Act (HIPPA) of 1996

A federal law passed in 1996 to protect privacy and other health care rights for patients. The act helps workers keep continuous health insurance coverage for themselves and their dependents when they change jobs, and protects confidential medical informa

Health maintenance organization (HMO)

A health plan that combines coverage of health care costs and delivery of health care for a prepaid premium.

Individual (or independent) practice association (IPA)

A type of HMO that contracts with groups of 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.


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

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.

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 health care consumers through proper licensing and regulation of physicians and other health care practitioners.

medical practice acts

state laws written for the express purpose of governing the practice of medicine


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.

patient portal

a secure online web site that gives patients 24-hour availability to health care providers.

patient protection and affordable care act (PPACA)

a federal law enacted in 2010, to expand health insurance coverage and otherwise regulate the health insurance industry. Many provisions of the law were scheduled to take effect in 2014 and 2015.

physician-hospital organization (PHO)

a health care plan in which physicians join with hospitals to provide a medical care delivery system and then contract for insurance with a commercial carrier or an HMO.

preferred provider organization (PPO)

a network of independent physicians, hospitals, and other health care providers who contract with an insurance carrier to provide medical care at a discount rate to patients who are part of the insurer's plan. Also called preferred provider association (P

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.

professional corporation

a body formed and authorized by law to act as a single person.


the process by which a professional license obtained in one state may be accepted as valid in other states by prior agreement without reexamination.


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

sole proprietorship

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


remote consultation by patients with physicians or other health professionals via telephone, closed-circuit television, or the internet.

Licensure, Certification, Registration and Accreditation
Lesson 3.1

With increased medical specialization have come more exacting professional requirements for health care practitioners. Members of the health care team today are usually licensed, registered, or certified to perform specific duties, depending on job classi


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. Individuals who do not have the requi


is a voluntary credentialing process, 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


is an entry in an official registry or record, listing the names of persons in a certain occupation who have satisfied specific requirements. The list is usually made available to health care providers. One way to become registered is simply to add one's

Under no circumstances may persons claim to be licensed, certified, or registered if they are not


Unlike licensing, certification, and registration as discussed earlier, (accreditation) does not refer to a qualification process for individuals practicing health care professions. Instead, it refers to a process or officially authorizing or approving he

* An assurance of high-quality standards at your school, based on the latest research and professional practice.
*An opportunity for you to participate in federal and/or state financial aid programs.
*A better chance that credits earned at your present sc

Two examples of accrediting agencies for health care practitioner education programs are the Commission on Accreditation of Allied Health Education Programs (CAAHEP), discussed in more detail later in the chapter, and the Accrediting Bureau of Health Educ


The Joint Commission (TJC) accredits health care organizations that meet certain standards including the following:

* General, psychiatric, Children's, and rehabilitation hospitals.
*Critical Access hospitals.
*Health care networks, including health maintenance organizations (HMOs), preferred provider organizations (PPOs), integrated delivery networks, and managed beha

To earn and maintain TJC accreditation, an organization must undergo an on-site survey by a TJC survey team at least every three years. Laboratories must be surveyed every two years.
A recognized accrediting agency for managed care plans is the National C

1. Through on-site reviews of key clinical and administrative processes.
2. Through the Healthcare Effectiveness Data and information Set (HEIS)- data used to measure performance in areas such as immunization and mammography screening rates.
3. Through us

participation in NCQA accreditation and certification programs is voluntary. At the NCQA Web site (, a person looking for quality medical facilities or health insurance plans can see rankings.


The commission on Accreditation of Allied Health Education Programs (CAAHEP) accredits more than 2,000 programs in 23 allied health professions throughout the United States and Canada. CAAHEP provides information concerning duties, education requirements,



For those professions that require a state license, such as physician, registered nurse, or licensed practical or vocational nurse, (reciprocity) may be granted. This means that a state licensing authority will accept a person's valid license from another