MAS 115 Medical Office Administration Chapters 1 ~ 3 Review for Exam
Some advantages of Managed Care include: <ul><li>100% coverage of approved treatment with very little out-of-pocket expens...
Capitation is: <ul><li>A fee ‘per head,’ usually per month, paid to the physician by a managed care insurance company </li...
Which type of medical practice has the advantage of shared liability? <ul><li>Solo practice </li></ul><ul><li>Associate pr...
They are two types of “permission” from patients to share PHI <ul><li>Consent ~ for routine transactions </li></ul><ul><li...
Examples of bioethical issues today include: <ul><li>IVF and other reproductive technologies, stem cell research, cloning,...
What’s malpractice? <ul><li>Literally “bad practice” </li></ul><ul><li>It means carelessness or negligence of a profession...
Bonding is <ul><li>Insurance against embezzlement </li></ul>
Can you name six ways an administrative medical assistant can protect their patient’s PHI?
Name some good characteristics that demonstrate a professional attitude: <ul><li>Initiative </li></ul><ul><li>Honesty </li...
Credentialing is <ul><li>Review of the physician’s curriculum vitae (resume); checking up on hospital, practice history an...
Some examples of Managed Care Organizations include: <ul><li>HMO </li></ul><ul><li>PPO </li></ul><ul><li>IPA </li></ul><ul...
HIPAA is <ul><li>The Health Insurance Portability & Accountability Act </li></ul><ul><li>Regulates the rules regarding pri...
Medical Practice Acts are <ul><li>State acts that regulate the requirements for obtaining a medical license </li></ul><ul>...
Tort is <ul><li>A tort is when one person causes injury to another person </li></ul>
Important interpersonal skills to have are: <ul><li>Observing </li></ul><ul><li>Showing interest, concern </li></ul><ul><l...
Three steps in coping with stress include: <ul><li>1)  Identify the cause of stress </li></ul><ul><li>2)  Evaluate the sit...
Five stages of dying (in order) are: <ul><li>Denial </li></ul><ul><li>Anger </li></ul><ul><li>Bargaining </li></ul><ul><li...
Hospice is <ul><li>Medical care and support for patients and families during terminal illness </li></ul>
HIPAA’s security rule covers: <ul><li>Physical and technical safeguards </li></ul><ul><li>Policies, procedures, documentat...
Who “owns” the medical record? <ul><li>The physician (or the health care organization itself) </li></ul>
Respondeat Superior means: <ul><li>Literally “let the master answer” </li></ul><ul><li>Figuratively it means that an emplo...
You do NOT need authorization to share PHI under these conditions: <ul><li>In emergencies </li></ul><ul><li>When mandated ...
An authorization is <ul><li>“Special” permission from a patient to share certain PHI with certain people regarding a certa...
A Consent is: <ul><li>“Routine” permission from a patient to share information regarding treatment, payment or other routi...
What’s a Compliance Officer? <ul><li>A person who oversees and monitors an organization’s HIPAA compliance plan </li></ul>
Misfeasance means <ul><li>Lawful or proper treatment but done incorrectly </li></ul>
Who oversees the Medical Practice Act? <ul><li>Each State Board of Medical Examiners oversees its own State Medical Practi...
HIPAA’s privacy rule defines patient’s rights which include: <ul><li>Patient’s have a right to receive notice about how an...
What’s the Good Samaritan Law? <ul><li>State laws (they vary) which protect off-duty health care workers and others from l...
Nonfeasance means <ul><li>Failure to treat when there was a duty to do so </li></ul>
Types of Contracts: <ul><li>Expressed Contract ~ Written or verbal agreement </li></ul><ul><li>Implied Contract ~ An agree...
What are some alternatives to litigation? <ul><li>Screening panel </li></ul><ul><ul><li>A physician review panel;  advisor...
What are some “defenses” the physician may use if sued? <ul><li>Contributory negligence  ~ the patient was in some way res...
Malfeasance means <ul><li>Improper or unlawful treatment </li></ul>
The 4D’s <ul><li>Are: </li></ul><ul><ul><li>Duty </li></ul></ul><ul><ul><li>Dereliction (of duty) </li></ul></ul><ul><ul><...
Some ways you can reduce litigation for your office/employer: <ul><li>Obey the LAW! </li></ul><ul><li>Work within the scop...
Examples of intentional torts include: <ul><li>Assault & Battery* </li></ul><ul><li>Invasion of Privacy* </li></ul><ul><li...
Examples of negligent (or UNintentional) torts might include: <ul><li>Accidentally administering incorrect dose </li></ul>...
What’s “Criminal Negligence?” <ul><li>Reckless disregard for, or indifference to, the welfare of a patient </li></ul>
What kind of comments could be perceived as “Promise to cure?” <ul><li>“You’ll be just fine…” </li></ul><ul><li>“Dr. Smith...
What is “stress?” <ul><li>Physical and psychological tension, caused by both “good” and “bad” events in our lives </li></ul>
It’s when a physician is not available when the patient seeks help <ul><li>Abandonment </li></ul><ul><li>Today, doctors mu...
Reasons a physician might terminate a contract with patient: <ul><li>Failure to pay for appointments </li></ul><ul><li>Fai...
How should a patient be informed their contract with physician is terminated?  <ul><li>In writing </li></ul><ul><li>Mailed...
What’s an advance directive? <ul><li>Legal form detailing the desires of the patient for procedures to either be performed...
Examples of advance directives: <ul><li>Living Will </li></ul><ul><li>Health Care Power of Attorney </li></ul><ul><li>Medi...
Some “advantages” for the patient with Traditional Care insurance (versus Managed Care): <ul><li>Patients feel they have m...
What is “Informed Consent” <ul><li>Remember it has two parts – “Informed” and “Consent” </li></ul><ul><li>Informed ~ docto...
Special rules about “Minors” <ul><li>States have varying laws about minors </li></ul><ul><li>Emancipated Minors can person...
Sources of stress include: <ul><li>Good </li></ul><ul><ul><li>Marriage </li></ul></ul><ul><ul><li>Birth of a baby </li></u...
What’s a gatekeeper? <ul><li>A primary care doctor who oversees the patient’s plan of care </li></ul><ul><li>This position...
Subpoena is <ul><li>Court order to appear </li></ul><ul><li>Subpoena duces tecum is </li></ul><ul><ul><li>Court order to a...
PHI stands for <ul><li>Protected Health Information </li></ul><ul><li>It includes personal identification and patient’s he...
Some reasons doctors are more likely to be sued today: <ul><li>Well educated public expects the best care regardless of ab...
What’s the difference between an “authorization” and a “pre-authorization? <ul><li>An authorization is special patient per...
What’s the difference between a consent and an informed consent? <ul><li>Consent is permission from a patient to share rou...
Some reasons for the rise in health care costs today include: <ul><li>Increased cost of a medical education </li></ul><ul>...
“ Think with empathy, act through ___________________”? <ul><li>SERVICE!   </li></ul>
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MAS 115 Review of Chapters 1 through 3

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  1. 1. MAS 115 Medical Office Administration Chapters 1 ~ 3 Review for Exam
  2. 2. Some advantages of Managed Care include: <ul><li>100% coverage of approved treatment with very little out-of-pocket expense </li></ul><ul><li>People are more likely to get preventative care since their insurance is pre-paid </li></ul>
  3. 3. Capitation is: <ul><li>A fee ‘per head,’ usually per month, paid to the physician by a managed care insurance company </li></ul>
  4. 4. Which type of medical practice has the advantage of shared liability? <ul><li>Solo practice </li></ul><ul><li>Associate practice </li></ul><ul><li>Group practice </li></ul>
  5. 5. They are two types of “permission” from patients to share PHI <ul><li>Consent ~ for routine transactions </li></ul><ul><li>Authorization ~ for special transactions </li></ul>
  6. 6. Examples of bioethical issues today include: <ul><li>IVF and other reproductive technologies, stem cell research, cloning, surrogacy, euthanasia </li></ul>
  7. 7. What’s malpractice? <ul><li>Literally “bad practice” </li></ul><ul><li>It means carelessness or negligence of a professional </li></ul>
  8. 8. Bonding is <ul><li>Insurance against embezzlement </li></ul>
  9. 9. Can you name six ways an administrative medical assistant can protect their patient’s PHI?
  10. 10. Name some good characteristics that demonstrate a professional attitude: <ul><li>Initiative </li></ul><ul><li>Honesty </li></ul><ul><li>Respectful </li></ul><ul><li>Dependable </li></ul><ul><li>Decisive </li></ul><ul><li>Accurate </li></ul><ul><li>Confidential </li></ul><ul><li>Ethical </li></ul>
  11. 11. Credentialing is <ul><li>Review of the physician’s curriculum vitae (resume); checking up on hospital, practice history and peer references; and often includes an oral interview </li></ul>
  12. 12. Some examples of Managed Care Organizations include: <ul><li>HMO </li></ul><ul><li>PPO </li></ul><ul><li>IPA </li></ul><ul><li>EPO </li></ul><ul><li>POS </li></ul>
  13. 13. HIPAA is <ul><li>The Health Insurance Portability & Accountability Act </li></ul><ul><li>Regulates the rules regarding privacy of protected health information (PHI) </li></ul>
  14. 14. Medical Practice Acts are <ul><li>State acts that regulate the requirements for obtaining a medical license </li></ul><ul><li>Designed to protect the public from “quackery” </li></ul>
  15. 15. Tort is <ul><li>A tort is when one person causes injury to another person </li></ul>
  16. 16. Important interpersonal skills to have are: <ul><li>Observing </li></ul><ul><li>Showing interest, concern </li></ul><ul><li>Watching your tone of voice </li></ul><ul><li>Empathy </li></ul><ul><li>Initiative </li></ul><ul><li>Teamwork </li></ul><ul><li>LISTENING! </li></ul>
  17. 17. Three steps in coping with stress include: <ul><li>1) Identify the cause of stress </li></ul><ul><li>2) Evaluate the situation ~ what can you do about it? </li></ul><ul><li>3) Confront the problem ~ Make a decision and do it! </li></ul>
  18. 18. Five stages of dying (in order) are: <ul><li>Denial </li></ul><ul><li>Anger </li></ul><ul><li>Bargaining </li></ul><ul><li>Depression </li></ul><ul><li>Acceptance </li></ul>
  19. 19. Hospice is <ul><li>Medical care and support for patients and families during terminal illness </li></ul>
  20. 20. HIPAA’s security rule covers: <ul><li>Physical and technical safeguards </li></ul><ul><li>Policies, procedures, documentation requirements </li></ul><ul><li>Risk analysis and management </li></ul><ul><li>Administrative safeguards </li></ul>
  21. 21. Who “owns” the medical record? <ul><li>The physician (or the health care organization itself) </li></ul>
  22. 22. Respondeat Superior means: <ul><li>Literally “let the master answer” </li></ul><ul><li>Figuratively it means that an employer can be held liable for the actions of its employees </li></ul>
  23. 23. You do NOT need authorization to share PHI under these conditions: <ul><li>In emergencies </li></ul><ul><li>When mandated by the State to report communicable diseases or concerning conditions </li></ul><ul><li>When subpoenaed by a court of law </li></ul><ul><li>Federally-funded programs automatically have authorization to receive certain PHI </li></ul>
  24. 24. An authorization is <ul><li>“Special” permission from a patient to share certain PHI with certain people regarding a certain timeframe </li></ul>
  25. 25. A Consent is: <ul><li>“Routine” permission from a patient to share information regarding treatment, payment or other routine health care operations </li></ul>
  26. 26. What’s a Compliance Officer? <ul><li>A person who oversees and monitors an organization’s HIPAA compliance plan </li></ul>
  27. 27. Misfeasance means <ul><li>Lawful or proper treatment but done incorrectly </li></ul>
  28. 28. Who oversees the Medical Practice Act? <ul><li>Each State Board of Medical Examiners oversees its own State Medical Practice Act </li></ul>
  29. 29. HIPAA’s privacy rule defines patient’s rights which include: <ul><li>Patient’s have a right to receive notice about how an organization is sharing their PHI </li></ul><ul><li>They have a right to access their own records </li></ul><ul><li>They have a right to ask for amendment to their own records </li></ul><ul><li>They have a right to ask a health care organization for an “accounting” – when and to whom were their records released? </li></ul><ul><li>They have a right to restrict disclosures of information </li></ul>
  30. 30. What’s the Good Samaritan Law? <ul><li>State laws (they vary) which protect off-duty health care workers and others from liability when responding to emergencies </li></ul><ul><li>It’s intended to ENcourage health care workers to help…without fear of being sued </li></ul><ul><li>No duty = no contract and no 4D’s of negligence </li></ul><ul><li>HOWEVER ~ actions must be considered “prudent,” not reckless; nor can doctor “charge a fee” for service </li></ul>
  31. 31. Nonfeasance means <ul><li>Failure to treat when there was a duty to do so </li></ul>
  32. 32. Types of Contracts: <ul><li>Expressed Contract ~ Written or verbal agreement </li></ul><ul><li>Implied Contract ~ An agreement deduced from the situation (emergencies) or from the patient’s behavior </li></ul><ul><li>NOTE: No Contract exists during a “Good Samaritan” action (p. 79) </li></ul>
  33. 33. What are some alternatives to litigation? <ul><li>Screening panel </li></ul><ul><ul><li>A physician review panel; advisory but cannot bar litigation </li></ul></ul><ul><li>Arbitration </li></ul><ul><ul><li>Agreed upon before treatment; in some States this can be a binding decision </li></ul></ul><ul><li>No-fault insurance </li></ul><ul><ul><li>“Injured person is compensated without regard to fault” (p. 78) </li></ul></ul>
  34. 34. What are some “defenses” the physician may use if sued? <ul><li>Contributory negligence ~ the patient was in some way responsible for his or her own injuries (fully or partially) </li></ul><ul><li>Assumption of risk ~ the patient was informed of the risks of treatment but chose to consent anyway </li></ul><ul><li>Statute of Limitations ~ the time limit to take legal actions has passed/expired </li></ul>
  35. 35. Malfeasance means <ul><li>Improper or unlawful treatment </li></ul>
  36. 36. The 4D’s <ul><li>Are: </li></ul><ul><ul><li>Duty </li></ul></ul><ul><ul><li>Dereliction (of duty) </li></ul></ul><ul><ul><li>Direct Cause </li></ul></ul><ul><ul><li>Damages </li></ul></ul><ul><li>All four are necessary to prove negligence </li></ul>
  37. 37. Some ways you can reduce litigation for your office/employer: <ul><li>Obey the LAW! </li></ul><ul><li>Work within the scope of your training and be careful </li></ul><ul><li>Don’t ( assume and then ) admit fault </li></ul><ul><li>Don’t make promises </li></ul><ul><li>Don’t practice medicine without a license! </li></ul><ul><li>Keep timely, accurate records </li></ul><ul><li>AND ~ LISTEN and COMMUNICATE </li></ul>
  38. 38. Examples of intentional torts include: <ul><li>Assault & Battery* </li></ul><ul><li>Invasion of Privacy* </li></ul><ul><li>Defamation of Character </li></ul><ul><li>Libel or Slander </li></ul><ul><li>False Imprisonment* </li></ul><ul><li>Fraud </li></ul><ul><li>*MY NOTE: Some of these can be “negligent” torts as well – depends on “intent” of the accused </li></ul>
  39. 39. Examples of negligent (or UNintentional) torts might include: <ul><li>Accidentally administering incorrect dose </li></ul><ul><li>Accidentally faxing PHI to wrong number </li></ul><ul><li>Accidentally documenting information in the wrong chart… </li></ul><ul><li>Negligence occurs when we do not “behave in the way a prudent person who is similarly educated and trained would behave under comparable circumstances.” (p. 75) </li></ul><ul><li>MY NOTE: In health care, most lawsuits are regarding UNintentional torts </li></ul>
  40. 40. What’s “Criminal Negligence?” <ul><li>Reckless disregard for, or indifference to, the welfare of a patient </li></ul>
  41. 41. What kind of comments could be perceived as “Promise to cure?” <ul><li>“You’ll be just fine…” </li></ul><ul><li>“Dr. Smith will fix you right up…” </li></ul>
  42. 42. What is “stress?” <ul><li>Physical and psychological tension, caused by both “good” and “bad” events in our lives </li></ul>
  43. 43. It’s when a physician is not available when the patient seeks help <ul><li>Abandonment </li></ul><ul><li>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. </li></ul>
  44. 44. Reasons a physician might terminate a contract with patient: <ul><li>Failure to pay for appointments </li></ul><ul><li>Failure to appear for appointments </li></ul><ul><li>Failure to follow medical advice </li></ul>
  45. 45. How should a patient be informed their contract with physician is terminated? <ul><li>In writing </li></ul><ul><li>Mailed certified with return receipt </li></ul><ul><li>Letter should state reason, and allow enough time for patient to find new doc </li></ul><ul><li>Copy of letter and signed receipt should be filed in patient’s chart as “proof” of proper termination </li></ul><ul><li>PURPOSE: To avoid charge of abandonment </li></ul>
  46. 46. What’s an advance directive? <ul><li>Legal form detailing the desires of the patient for procedures to either be performed or withheld when death is imminent </li></ul>
  47. 47. Examples of advance directives: <ul><li>Living Will </li></ul><ul><li>Health Care Power of Attorney </li></ul><ul><li>Medical Directive </li></ul><ul><li>Values History Form </li></ul><ul><li>Health Care Proxy </li></ul><ul><li>DNR (Do Not Resuscitate) </li></ul><ul><li>Donor/Anatomical Gift Form </li></ul>
  48. 48. Some “advantages” for the patient with Traditional Care insurance (versus Managed Care): <ul><li>Patients feel they have more choice – they can see any doctor, any time, as often as they want (no ‘network’) </li></ul><ul><li>No pre-authorization is required so there are no delays in treatment, referrals, getting medications </li></ul>
  49. 49. What is “Informed Consent” <ul><li>Remember it has two parts – “Informed” and “Consent” </li></ul><ul><li>Informed ~ doctor explains risks, benefits, alternatives of recommended treatment and answers any questions </li></ul><ul><li>Consent ~ patient agrees to treatment after being informed, often “signing” a formal consent agreement </li></ul>
  50. 50. Special rules about “Minors” <ul><li>States have varying laws about minors </li></ul><ul><li>Emancipated Minors can personally consent to treatment (p. 80) </li></ul><ul><li>“Mature minor” is usually over 14 years of age and can often consent to medical/surgical treatment without parental consent </li></ul><ul><li>Reproductive Health issues: Abortion, pregnant unmarried minors – rules vary by State </li></ul>
  51. 51. Sources of stress include: <ul><li>Good </li></ul><ul><ul><li>Marriage </li></ul></ul><ul><ul><li>Birth of a baby </li></ul></ul><ul><ul><li>Better Job </li></ul></ul><ul><ul><li>Moving </li></ul></ul><ul><li>Bad </li></ul><ul><ul><li>Divorce </li></ul></ul><ul><ul><li>Death </li></ul></ul><ul><ul><li>Loss of job </li></ul></ul><ul><ul><li>Health issues </li></ul></ul>
  52. 52. What’s a gatekeeper? <ul><li>A primary care doctor who oversees the patient’s plan of care </li></ul><ul><li>This position is designed to help Managed Care control costs by scrutinizing referrals, pre-authorizing tests or drugs, etc. </li></ul>
  53. 53. Subpoena is <ul><li>Court order to appear </li></ul><ul><li>Subpoena duces tecum is </li></ul><ul><ul><li>Court order to appear with records </li></ul></ul>
  54. 54. PHI stands for <ul><li>Protected Health Information </li></ul><ul><li>It includes personal identification and patient’s health information </li></ul>
  55. 55. Some reasons doctors are more likely to be sued today: <ul><li>Well educated public expects the best care regardless of ability to pay; when they don’t get it, they may sue </li></ul><ul><li>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 </li></ul><ul><li>Bioethical issues generate lawsuits – new, untested legal ground = lawsuits </li></ul><ul><li>Managed care can cause delays in approvals, testing, diagnosis = lawsuits </li></ul>
  56. 56. What’s the difference between an “authorization” and a “pre-authorization? <ul><li>An authorization is special patient permission to share certain PHI </li></ul><ul><li>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. </li></ul>
  57. 57. What’s the difference between a consent and an informed consent? <ul><li>Consent is permission from a patient to share routine health care information with insurance companies, other people involved in their care </li></ul><ul><li>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 </li></ul>
  58. 58. Some reasons for the rise in health care costs today include: <ul><li>Increased cost of a medical education </li></ul><ul><li>Increased lawsuits cause increase in medical malpractice insurance </li></ul><ul><li>Longer life expectancy = more people with chronic health issues = increased costs </li></ul><ul><li>Increased technology = increased specialization = higher cost for personnel </li></ul><ul><li>Docs over-prescribing, over-testing to reduce liability = wasteful = higher costs </li></ul>
  59. 59. “ Think with empathy, act through ___________________”? <ul><li>SERVICE! </li></ul>

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