HITT 1401-LectureExam3

  2. 1a. Describe the major fucntion of DHHS
    Responsible for regulating the health care industry
  3. 1b. Describe the general organizational structure of DHHS
    Divided into 11 operating divisions
  4. 1c. Describe the major function of CMS
    Administers the Medicare and Medicaid programs
  5. 2a. Describe SSA
    Responsible for administration of programs provided by the Social Security Act of 1935
  6. Describe EPA
    • Responsible for administering programs provided by Environmental Protection Act:
    • Establishment & enforcement of environmental protection standards
    • Research on effects of pollution
    • Regulation of hazardous waste disposal
  7. OHSA?
    • Occupational Safety and Health Act:
    • Promotion of safe and healthful working conditions
    • Use and storage of hazardous material
    • Use of protective wear
    • Sharps disposal
  8. Nuclear Regulatory Commission (NRC)
    • License and oversee construction and operation of nuclear reactors
    • Regulate packaging, storage, usage and disposal of radioactive materials
    • Radiation warning sign:
  9. Texas Department of State Health Services (DSHS)
    • An agency of the Texas Health and Human Services System
    • Licenses health care facilities
    • Administers CMS rules and regulations on a local basis
    • Serves as a clearinghouse for various state agencies
    • Operates public health department clinic
  10. 3. Licensure?
    • A state function
    • In Texas, licensure of healthcare facilities is under the direction of the ????
    • Usually renewable annually
    • Fee charged
    • Based on compliance with: legal requirements life and safety codes, necessity (in certain cases)
  11. 3. Accreditation?
    • A voluntary process which is intended to demonstrate that a facility or institution meets or exceeds an expected level of quality
    • Basis for health care accreditation: Standards of care –
    • Established measures that represent expected levels of performance
    • Results of on-site visits
    • Accreditation fee is charged to the facility
  12. 3. Certification?
    • The process by which a healthcare facility is approved to receive federal and/or state funding for the care provided to Medicare, Medicaid and TriCarepatients
    • Mandatory in order for a healthcare facility to receive payment for MC/MC/TC patients
    • Administered by CMS, Delegated to DSHS in Texas
  13. American Osteopathic Association (AOA)
    The AOA's mission is to advance the philosophy and practice of osteopathic medicine by promoting excellence in education, research, and the delivery of quality, cost-effective healthcare, deeming status and accredits Osteopathic facilities
  14. 4b. The Joint Commission on Accreditation of Healthcare Organizations (TJC, JCAHO
    is a United States-based nonprofit organization that accredits more than 19,000 health care organizations and programs in the United States
  15. Self pay
    • Self Pay
    • Non-insured Person receiving care is responsible for paying the bill Payment is due at the time of discharge Arrangements may be made in most facilities
    • Non-pay
    • The recipient is not able to pay and is not covered by insurance
    • Third party payer
    • An entity other than the person receiving services is responsible for paying all or part of the bill 
    • Types:
    •  Private insurance companies
    •  Government-funded insurance
    •  Managed care organizations
  16. 6. Medicaid
    • Medicaid (Title XIX of the Social Security Act)
    • Funding:  federal and state (states may pay up to 50%)
    • Based on income eligibility
  17. 6. Medicare
    • Medicare (Title XVIII of the Social Security Act)
    • Funding:  100% federal
    • Age 65+ or Qualifying condition
    • Medicare coverage
    • Part A - Inpatient hospitalization
    • Part B -Physician services, Outpatient services
    • Part C (Medicare Advantage Plan)-private HMO plans
    • Part D - Prescription Drug Plan
  18. 7a. Prospective payment to Inpatient Services?
    Diagnosis related groups (DRG's) handles Inpatient hospital services refer to those services that a hospital provides under the direction of either a physician
  19. 7b. Prospective payment to Outpatient Services?
    Ambulatory Patient Classifications (APC's) - Outpatient services are medical procedures or tests that can be done in a medical center without an overnight stay
  20. 7c. Prospective payment to Physician Services?
    Resource-based Relative Value Scales (RBRVSs)
  21. 8. Health maintenance organizations (HMO)?
    InNetwork plan, A health maintenance organization (HMO) is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals and other entities in the United States as a liaison with health care providers (hospitals, doctors, etc.) on a prepaid basis.
  22. 8. Prefered provider organizations (PPO)?
    Out Of Network plan whit co-pay percentage
  23. 9. Describe methods utilized by managed care organizations to control healthcare cost.       
    A Gate keeper whom is the primary care physician  and an approval mechanism called HMO and PPO
  24. 10a. SSA
    SSA of 1935 (and know what SSA stands for) Social Security Act, retirement stipend, disability payments based on qualifying disabity
  25. 10b. TEFRA
    TEFRA (and know what TEFRA stands for) Tax Equity and Fiscal REsponsibility Act of 1982, created DRGs. TEFRA was created in order to reduce the budget gap by generating revenue through closure of tax loopholes and introduction of tougher enforcement of tax rules, as opposed to changing marginal income tax rates.
  26. 10c. HIPPA
    HIPAA (and know what HIPAA stands for) - Health Insurance Portability and Accountability Act of 1996, enable patient portability of insurance from one employer to another, pertain to health information confidentiality, and security of electronic health information and systems
  27. 10d. Hill-Burton Act of 1946 and the amendments of the 1980's
    Hill-Burton Act of 1946 and the amendments of the 1980's - Appropriated money for communities that wanted to build additional hospitals, amendments appropriated money for remodeling
  28. 10e. COBRA
    Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) address insurance coverage when loss of employment but know as Patient Antidumping law
  29. 10f. EMTALA
    Emergency Medical Treatment and Active Labor Act (EMTALA) any patient in a try life threatening emergency or in active labor would not be turned away
  30. 10g. MMA
    MMA of 2003 (and know what MMA stands for) Medicare Modernization Act of 2003, created Medicare Part D, the way information was reported to CMS
  31. 10h. Affordable Care Act of 2010
    Affordable Care Act of 2010 ( and know the full name of the law) formal name is Patient Protection and Affordable Care Act of 2010, extended coverage to non-insured or underinsured
  32. 10i. Describe some of the trends or forces that have impacted the delivery of healthcare in the U.S. since 1965 - adelhack page 8
    Hospitalists may require changes in education and training, develop competing goals and priorities, and face new issues in their relationships with health plans, hospitals, and other physicians.
  33. 10k. Describe the impacts of prospective payment on physicians, hospitals, hospital employees and patients 
    Prospective payment system in place, it put a cap health care cost by reducing what federal and state on health care and private insurers followed suit, physicians reduced services, hospitals reduced services and development of non acute health care facilities, to to reduced services, staff can now be reduced, and patients stay is reduced, or care given from employee may not be as knowledgable outside there field, longer wait times.
  34. 11. Define
    • Define       
    • a. biohazard - materials that are potentially infectious with disease-carrying microorganisms       
    • b. prospective payment - payment is based on a pre-determined fixed rate       
    • c. retrospective payment - payments based on actual charges for a particular service, and rage times LOS
    • d. gatekeeper - primary care physician       
    • e. payer - person or entity responsible for making payment
  35. Define:
    a. Title XVIII      
    b. Title XIX     
    c. EMTALA
    d. TDSHS
    • a. Title XVIII (18) - Medicare       
    • b. Title XIX (19) - madicade       
    • c. EMTALA - emergency medical treatment and labor act       
    • d. TDSHS - texas department of state health services
  37. 1a. Define medical staff
    The formally organized staff of licensed physicians and other licensed providers as permitted by law Have authority and responsibility to maintain proper standards of medical care Governed by its own bylaws, rules and regulations
  38. 1b. Clinical Privileges
    The permission granted by the appropriate authority to practitioners to provide welldefined patient care services in the granting institution
  39. 1c. Appointment
    The act of appointing or designating someone for an office or position.
  40. 1d. Reappointment
    The act of reappointing, or the state of being reappointed.
  41. 1e. Privilege delineation
    The specific process for physician credentialing and delineation of clinical privileges must be defined by medical staff and department bylaws, policy, rules, or regulations. Each member of the medical staff must be subject to periodic review as part of the performance improvement activities of the organization.
  42. 2a. Allopathy
    Origin: ancient Greek physicians Basis: Producing a condition incompatible with or antagonistic to the disease or condition being treated Emphasis: Symptom relief, cure when possible
  43. 2a. Osteopathy
    Origin: Dr. Andrew Taylor Still Basis: Relationship between the skeletal, lymphatic and vascular systems Emphasis: body mechanics and manipulative methods of correcting faulty structure OMT
  44. 2b. Requirements, MDs and DOs
    • MDs Education: Bachelor’s degree, MCAT, + 4years medical school
    • License: USMLE 

    • DOs Education: Bachelor’s degree, MCAT, + 4years osteopathic medical school
    • License: USMLE + add’l section on osteopathic technique
  45. Physician Licensure Requirements
    • MDs License: USMLE
    • DOs  License: USMLE + add’l section on osteopathic technique
  46. 3. Non- Departmentalized Staff
    The MS acts as one committee to carry out all assigned responsibilities Must be able to meet regularly to conduct business
  47. 3b. Departmentalized Staff
    The MS is divided into services or departments, usually by specialty Each can be further subdivided, depending on size of medical staff
  48. 4. Medical Staff 5 Categories
    • Associate (Provisional) -Those physicians who have not yet been elevated to active staff
    • Active (Full) - Those physicians with full voting and membership privileges and responsibilities
    • Courtesy - Those physicians who have met the requirements for active staff, but admit patients only occasionally
    • Consulting - Those physicians who do not normally admit patients, but who may be called in on unusually complicated casesHonorary - Granted to outstanding physicians in recognition of their contributions to the facility and the community
  49. 5. Define: Teaching hospitals position only: 􏰁 Externs 􏰁 Interns 􏰁 Residents
    • Externs - 3rd and 4th - year medical school students
    • Interns - Medical school graduates in their first year after graduation, Are not licensed physicians
    • Residents - Medical school graduates, Have passed USMLE, Length of residency depends on specialty
  50. 6. Document that delineates medical staff policies?
    Clinical Privileges - The permission granted by the appropriate authority to practitioners to provide well- defined patient care services in the granting institution
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HITT 1401-LectureExam3