Chapter 2 - Working in Health Care McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved 2-1.

Chapter 2 - Working in Health Care

McGraw-Hill © 2010 by The McGraw-Hill Companies, Inc. All rights reserved

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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 today’s health care environment.

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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.

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Licensure Mandatory

credentialing process Required for a variety

of health care practitioners Nurses Physicians Dentists Pharmacists PA’s, ARNP’s

Done by state

Certification Voluntary

credentialing process Usually sponsored by

a professional association

Is national in scope, often requiring documentation of education

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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.

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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

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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.

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Many states will accept a person’s valid license from another state—this is reciprocity.

Those states that will not allow reciprocity require the individual to take an examination to be licensed in their state.

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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

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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

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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.

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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.

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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.

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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

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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

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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

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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)

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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

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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

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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?

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