CCMA FINAL EXAM STUDY GUIDE 4

what is patient care coordination?

organization of patient care activities and sharing information with all parties concerned with a patient's care to achieve safer and more effective care

what is the main goal of care coordination?

to meet patient's needs and preferences while delivering high quality, high value health care. the patient's needs and preferences are known and communicated at the right time to the right people. that information is used to guide the delivery of safe, appropriate and effective care

why is care coordination important?

shift from treating illness to promoting health

what is team based patient care?

provision of health services to individuals, families, and their communities by at least two health providers who work collaboratively with patients and their caregivers to accomplish shared goals within and across settings to achieve coordinated, high quality cate

what are two health care delivery models that practice team based patient care?

1. patient centered medical home (PCMH)

2. accountable care organization

what is patient centered medical home (PCMH)?

approach to delivering high quality, cost effective primary care

includes health care delivery that is: patient centered, accessible, comprehensive, coordinated, continuous, committed to quality and safety

what are accountable care organizations (ACOs)?

groups of doctors, hospitals, other health care providers who come together voluntarily to give coordinated high quality care to their medicare patients

what is the goal of coordinated care?

to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors

what is transition care?

movement of a patient from one setting of care to another

safe and effective transfer of responsibility for a patient's medical care relies on effective provider communication with patient comprehension of discharge instructions and thorough education

what are examples of settings of care?

1. hospitals

2. ambulatory primary care practices

3. ambulatory specialty care practices

4. long term care facilities

5. home health

6. rehabilitation

what is medicare access and CHIP reauthorization act of 2015 (MACRA)?

law that reformed the medicare payment system. incorporates quality perfomance measurements into payments with the goal of creating an equitable payment system for physicians

includes:

1. quality

2. cost/resource use

3. clinical practice improvement

4. advancing care information

what is patient education?

educating the patient about medications, treatment options, increasing physical activity, eating a healthy diet

what are the three learning styles?

1. auditory learning

2. kinesthetic learning

3. visual learning

what is auditory learning?

learning by hearing and listening, understand remember things you have heard. you store information by the way it sounds, you have an easier time understanding spoken instructions than written ones

what is kinesthetic learning?

learning that requires you to manipulate or touch material. need to see the action and then perform it back

what is visual learning?

learning by using images, graphics, colors, maps to communicate ideas and thoughts

scheduling software helps medical assistants manage appointments and bookings, this can include:

1. desktop applications - on computer to create reports and handle scheduling

2. web based systems - third party service offers appointment scheduling tools and features accessible by multiple users

scheduling methods include:

1. wave scheduling

2. modified wave scheduling

3. double booking scheduling

what is wave scheduling?

allows 3 patients to be scheduled at the same time, in the order that they arrive

what is modified wave scheduling?

allows 2 patients to arrive at the same scheduled time and the third to be scheduled 30 minutes later

what is double booking scheduling?

two patients are scheduled at the same time to see the same provider. this allows for a patient with an acute illness to be seen when no time is available

when scheduling a new patient, what will you need to include?

1. full name

2. address

3. DOB

4. phone number

5. insurance information

6. SS#

7. emergency contact information

when a patient is filling out the registration packet, what does it include?

1. privacy notice

2. demographic information

3. medical history

4. current medications

what are the steps for paper record filing?

1. conditioning

2. releasing

3. indexing and coding

4. sorting

5. storing and filing

what are the three basic filing methods?

1. alphabetic

2. numeric

3. subject filing

what is legal requirements related to maintenance, storage, and disposal of records?

state laws or regulations define the requirements and conditions related to medical records. in the absence of these laws, HIPPA privacy rule prevails

what is HIPAA?

Health Insurance Portability and Accountability Act - federal law that sets a national standard to protect medical records and confidential patient informations

what is the privacy act of 1974?

gives individuals right to access and request amendments to their medical record

to meet federal and criteria to qualify for CMS incentive, the provider must

use the system for e-prescribing, communicating with patients, and computerized provider order entry (CPOE) which includes laboratory and radiology orders

what are a few of the safety measures built into electronic health record (EHR) systems to protect your medical record?

1. access control tools like passwords, PIN numbers, to limit access to patient information to authorized individuals

2. encrypting stored information - health information cannot be read or understood except by someone who can decrypt it, using a special "key" made available only to authorized individuals

what is co-insurance?

policy provision frequently found in medical insurance whereby the policyholder and insurance company share the cost of covered losses in a specified ratio (80/20 - 80% covered by insurer, 20% covered by insured)

what is a co-pay?

specified sum of money based on the patient's insurance policy benefits due at the time of service

what is a deductible?

specific amounts of money a patient must pay out of pocket before the insurance carrier begins paying. this amount ranges from $100 to $500. deductible met annually or per incident basis

what is explanation of benefits (EOB)?

letter or statement from insurance carrier describing what was paid, denied, reduced in payment. contains information about amounts applied to deductible, patient's co insurance, and allowed amounts

what is remittance advice?

explanation of benefits sent to the provider from the insurance carrier. includes the electronic fund transfer information or check for payment. used to post payments to patient accounts

what is advance beneficiary notice (ABN)?

aka waiver of liability

notice a provider should give before you receive a service - if based on medicare, provider may believe medicare won't pay for services

NOT an official medicare coverage decision

what types of insurance plans are federal?

1. medicare

2. tricare

3. workers' compensation

what is medicare?

federally sponsored health insurance program for those over 65 and under 65 who are disabled

what is TRICARE?

government sponsored program which authorized dependents of military personnel receive medical care

what is workers' compensation?

system of laws that protects employees against the loss of wages and the cost of medical care resulting from an occupational accident, disease, or death unless employee is proven negligent

what are private policies regarding types of insurance plans?

includes group policies offered through an individual's employer who will usually pay a portion of the premium and deduct the remainder of the premium from the employee's paycheck.

to verify coverage for federal or private policies insurance plans, what information must you have?

1. patient's full name

2. DOB

3. policy number

4. SS#

what are the types of medical coding systems?

1. ICD-10-CM

2. ICD-10_PCS

3. CPT codes & modifiers

4. HCPCS

what is ICD-1-_CM coding system?

seven character, alphanumeric code

each code begins with a letter, that is followed by two numbers

what is ICD-10-PCS coding system?

medical classifications for procedural codes, used within hospitals that record various treatments and testing

what is CPT codes and modifiers regarding to the medical coding system?

used to document procedures and technical services based on services by providers in outpatient settings

what is HCPCS regarding the medical coding system?

group of codes and descriptions that represent procedures, supplies, products, services, not covered by CPT coding system

updated every year, used to enhance uniform reporting and collection statistical data on medical supplies, products and services

used for medicaid and medicare insurance plans

how long does a regular referral take?

3-10 business days

how long does an urgent referral take?

24 hours

how long does a STAT referral take?

ASAP - provider may have to justify the referral via peer-to-peer review with UM department

what is account balance?

total balance on the account

what is debit?

negative

what is credit?

positive

what are accounts receivable?

amount owed to the provider for services

what are accounts payable?

is money owed by a business to its suppliers shown as a liability on a company's balance sheet

what are assets?

objects or property of an individual or organization that is subject for debts

what are liabilities?

outstanding liability

what are the communication styles?

1. analytical communicator

2. intuitive communicator

3. functional communicator

4. personal communicator

what is an analytical communicator?

prefers to work with numbers, facts, data. little emphasis of feelings

what is an intuitive communicator?

looks at the big picture but can be confusing if the approach is too broad

what is a functional communicator?

takes an organizes approach with detailed plans, uses step by step method to solve problems

what is a personal communicator?

uses emotional language, deeply cares about what people think and feel. they can be good listeners and are able to resolve conflicts

what are ways to engage with patients and family members?

1. include the patient in the process

2. practice active listening

3. communicate effectively

what are ways to engage in crucial conversations?

1. consider safety first

2. demonstrate empathy, not sympathy

3. stick with facts

4. watch words and actions

5. use active listening

what are the defense mechanisms?

1. denial

2. regression

3. projection and displacement

4. repression

5. sublimination

what are techniques to work with angry patients?

1. remain calm

2. use active listening

3. use therapeutic communication

4. display empathy and apologize

5. offer a solution

what is medical ethics and law?

healthcare law refers to federal, state, and local laws, rules, regulations among providers, payers and vendors to the healthcare industry and its patient and delivery of healthcare services: all with emphasis on operations, regulatory and transactional legal issues

what is civil law?

the law that pertains to persons, things, and relationships that develop among them. the most often applied to medical malpractice cases

what is criminal law?

deals with punishment of people and entities that break laws. behaviors that are or can be construed as offenses against the public, society or state, even if a crime affects a private individual. conviction results in a fine or imprisonment

what is administrative law?

body of law in the form of decisions, rules, regulations and orders created by administrative agencies under direction of the federal government to carry out duties of those agencies,

agencies are responsible for protecting civil rights. privacy, safety of its citizens

administrative law includes

1. regulation and operation of social security administration

2. administration of benefits to the people

what are the 2 major classifications of tort?

1. intentional

2. negligence

what is intentional tort?

deliberate act that violates the rights of another

what is negligence tort?

unintentional and most common in malpractice cases

violation of state medical practice acts can result in healthcare worker being accused of

1. malfeasance

2. misfeasance

3. negligence

4. nonfeasance

what is malfeasance?

act that is illegal and causes physical or monetary harm to someone else. it is intentional conduct that is wrongful or unlawful, especially by officials or public employees

what is misfeasance?

act that is lawful, but performed in an unlawful, illegal or injurious manner

what is negligence?

failure to behave with the level of care that someone ordinary prudence would have exercised under the same circumstances. the behavior usually consists of actions but can also consist of omissions when there is some duty to act

what is nonfeasance?

the failure to do something that one is legally responsible to do. an intentional failure to live up to one's legal or moral duty in each situation, a refusal to fulfill one's obligation

what is affordable care act?

law enacted to decrease the growth in healthcare spending in the US and to help provide more Americans with affordable quality health insurance

what is Occupational Safety and & Health Administration (OSHA)?

law makes employers accountable for providing a safe and healthy work environment for employees through training, outreach, education and assistance

what is Health Insurance portability & Accountability Act of 1996 (HIPPA)?

gives patients rights over their health information and sets rules and limits on who can look at and receive patient's private information

what is The Health Information Technology for Economic and Clinical Health Act (HITECH)?

part of the American Recovery and Reinvestment Act of 2009, February 17th 2009.

to promote the adoption and meaningful use of health information technology. the HITECH addresses the privacy and security concerns associated with electronic transmission of health information, in part through several provisions that strengthen the civil and criminal enforcement of the HIPPA rules

what is control substance act (CSA)?

regulates the manufacture and distribution of controlled substances - narcotics, depressants, stimulants. CSA classifies medications into 5 schedules, based on likelihood abuse and any medical benefit the substance may have

what is Americans with Disability Act (ADA)?

forbids discrimination against any applicant or employee who could perform a job regardless of a disability

requires an employer to provide accommodations that are necessary to help the employee perform a job successfully, unless the accommodations are not possible

what is family medical leave act (FMLA)?

federal law that requires certain employers to give time off to employees for familial or medical reasons

what is the Joint Commission Act?

helps healthcare organizations position for the future of integrated care, strengthen patient safety and quality care, improve risk management and risk reduction and provide a framework for organizational structure and management

what is scope of practice?

permissible activities for members of a healthcare profession. the scope is determined by laws within a particular state, professional standards boards, and the administrators of specific healthcare facilities

what is CCMA scope of practice?

duties can vary from facility to facility and state to state

what is ethics?

discipline concerned with what is morally good, and bad or right and wrong. an individual's personal morals and religious upbringings often contribute to their personal ethics

professional ethics are a set of accepted behaviors and values that a person is expected to possess in a particular organization or profession, such as

1. hippocratic oath

2. code of ethics

what are medical directives?

set of requests that patients put in writing for their provider, family and other health care professionals to carry out surrounding end of life medical treatment

what are the types of medical directives?

1. the living will

2. durable power of attorney

3. do not resuscitate orders

4. polst

5. organ tissue and donation

what is the living will?

legal document that states what procedures that a patient would want, which one's they would not want and under what conditions such as dialysis, blood transfusions, and DNR orders

what is durable power of attorney?

medical power of attorney - legal document in which you name a person to be a proxy (agent) to make your health care decisions if you become unable to do so

what is do-not-resuscitate?

resuscitation means medical staff will try to re-start your heart and breathing using methods such as CPR and AED or breathing machines

what is POLST?

form also helps describe your wishes for healthcare, but it is not an advance directive

has a set of specific medical orders that a serious ill person can fill in and ask their health care provider to sign

addresses your wishes in an emergency, such as whether to use CPR

what is organ tissue and donation?

process when a person allows an organ of their own to be removed and transplanted to another person, legally

how can an MA maintain patient privacy?

1. never leave confidential patient information on a fax machine

2. always used a cover page

3. shred medical information when needed

4. be sure that the fax machine, copier, and computer are not visible to patients

5. HIPPA complaint process

anyone can file a health information privacy or security complaint, the complaint must:

1. be filed in writing by mail, fax, email or via OCR complaint portal

2. name the covered entity or business associate involved, and describe the acts or omissions, you believed violated the requirements of privacy, security, or breach notification rules

3. be filed within 180 days of when you knew that the act or omission complained of occurred. OCR may extend the 180 day period if you can show "good cause"