Regulatory Aspects of Healthcare

  1. Department of Health and Human Services
    • Major Function: Responsible for regulating the health care industry
    • General Organizational Structure: 11 Operating Divisions, 10 Regional Offices
  2. Centers for Medicare/Medicaid Services
    Main Function: Administers the Medicare/Medicaid Programs
  3. Social Security Administration
    Responsible for administration of programs provided by the Social Security Act of 1935
  4. Occupational Health and Safety Administration (OSHA)
    • Responsible for administering programs provided by the Occupational Safety and Health Act 
    • Promotion of safe and healthful working conditions 
    • Use and storage of hazardous materia
    • Use of protective wear 
    • Sharps disposal
  5. Environmental Protection Agency (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
  6. Nuclear Regulatory Commission
    Regulate packaging, storage, usage and disposal of radioactive materials
  7. Texas Department of State Health Services (DSHS)
    • Licenses health care facilities
    • Administers CMS rules and regulations on a local basis
    • Serves as a clearing house for various state agencies
    • Operates public health department clinics
  8. Licensure
    • A state function
    • In Texas, licensure of healthcare facilities is under the direction of the Texas Department of State Health Services
    • Usually renewable annually
    • Fee charged
    • Based on compliance with
    • legal requirements
    • life and safety codes
    • necessity (in certain cases)
  9. 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
  10. 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 TriCare patients
    • Mandatory in order for a healthcare facility to receive payment for MC/MC/TC patients
    • *Administered by CMS
    • Delegated to DSHS in Texas
  11. American Osteopathic Association (AOA)
    Major Role: To advance the philosophy and practice of osteopathic medicine by promoting excellence in education, research, and the delivery of quality, cost-effective healthcare
  12. The Joint Commission on Accreditation of Healthcare Organizations (TJC, JCAHO)
    Major Role: To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value
  13. 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
  14. Non-Pay
    The recipient is not able to pay and is not covered by insurance
  15. 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. Medicare
    • Funding: 100% federal
    • Age 65+ or Qualifying condition
  17. Medicaid
    • Funding: federal and state (states may pay up to 50%)
    • Based on income eligibility
  18. Medicare coverage- Part A (no premium)
    • Inpatient hospitalization
    • SNF (limited)
    • Home health (limited)
    • Hospice (limited)
  19. Medicare coverage- Part B (premium usually required)
    • Physician services
    • Outpatient services
    • DME (Durable Medical Equipment) 
    • PT, OT, ST
  20. Medicare coverage- Part C (Medicare Advantage Plan)
    Parts A & B coverage through private HMO plans
  21. Medicare coverage- Part D (premium usually required)
    Prescription Drug Plan
  22. Medicaid Coverage
    • Coverage is based on income eligibility, regardless of the type of facility / level of service
    • Coverage varies by state
    • Texas- Inpatient; Outpatient; Physician services; Family planning; Long term care
  23. Prospective Payment System- Diagnosis Related Groups (DRG)
    Inpatient Services
  24. Prospective Payment System- Ambulatory Patient Classifications (APC)
    Outpatient Services
  25. Prospective Payment System- Resource Based Relative Value Scales (RBRVS)
    Physician Services
  26. Health Maintenance Organization (HMO)
    • In network physicians only!
    • Can't go out of network
    • PCP gives referrals to specialist
  27. Preferred Provider Organization (PPO)
    • Allowed to go out of network, but pay a percentage
    • Preferred providers list, no need for referrals
  28. Methods used by Managed Care Organizations to control healthcare costs
    • Costs are managed through
    • Gatekeeper- PCP 
    • Approval mechanism-
  29. Social Security Administration of 1935 (SSA)
    An independent agency of the United States federal government that administers Social Security, a social insurance program consisting of retirement, disability, and survivors' benefits. To qualify for these benefits, most American workers pay Social Security taxes on their earnings; future benefits are based on the employees' contributions.
  30. Tax Equity and Fiscal Responsibility Act of1982 (TEFRA)
    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
  31. Health Insurance Portability & Accountability Act (HIPAA)
    • 1. Regulates the availability and breadth of group health plans and certain individual health insurance policies
    • 2. Defines policies, procedures and guidelines for maintaining the privacy and security of individually identifiable health information as well as outlining numerous offenses relating to health care and sets civil and criminal penalties for violations. It also creates several programs to control fraud and abuse within the health care system
  32. Hill-Burton Act of 1946 & 1980’s amendments
    • Law that gave hospitals, nursing homes and other health facilities grants and loans for construction and modernization.
    • In return, they agreed to provide a reasonable volume of services to persons unable to pay and to make their services available to all persons residing in the facility’s area
  33. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
    • Known as the “Patient Antidumping Law"
    • Insurance program giving some employees the ability to continue health insurance coverage after leaving employment
  34. Emergency Medical Treatment and Active Labor Act (EMTALA)
    It requires hospitals to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to pay
  35. Medicare Modernization Act of 2003 (MMA)
    Created Medicare Part D- prescription drug improvement plan
  36. Patient Protection and Affordable Care Act of2010
    • PPACA is aimed primarily at decreasing the number of uninsured Americans and reducing the overall costs of health care.
    • PPACA requires insurance companies to cover all applicants and offer the same rates regardless of pre-existing conditions or gender.
  37. Describe some of the trends or forces that have impacted the delivery of healthcare in the U.S. since 1965
  38. Describe the impacts of prospective payment on physicians, hospitals, hospital employees and patients
    • Reduced federal & state payments
    • Reduced services
    • Shorter length of stay
    • Cutting staff
    • Longer waiting period
  39. Biohazard
    Materials that are potentially infectious with disease-carrying microorganisms
  40. Prospective Payment
    Payment is based on a pre-determined fixed rate
  41. Retrospective Payment
    • Payment is based on actual charges
    • Charge for a particular service
    • Rate x LOS
  42. Gatekeeper
    a primary care physician, with a role of rationing patient access to specialized medicine
  43. Payer or Payor
    A company or an agency that purchases health services
  44. Title XVIII of the Social Security Act
    Government Insurance Program- Medicare
  45. Title XIX of the Social Security Act
    Government Insurance Program- Medicaid
  46. TDSHS
    Texas Department of State Health Services
  47. EMTALA
    Emergency Medical Treatment and Active Labor Act
Card Set
Regulatory Aspects of Healthcare
Study Questions