CH. 1 (CCMA Exam)

Chapter 1: Health Care Systems and Settings Exam: Certified Clinical Medical Assistant NHA (National Healthcare Association)

Medical Doctors (MDs)

• allopathic providers.

• diagnose illnesses, provide treatments, perform surgical procedures, and write prescriptions.

Osteopathic Providers (DOs)

• similar to MDs.

• in addition to modern medicine and surgical procedures, DOs use osteopathic manipulative therapy (OMT) in treating patients.

Nurse Practitioners

• basic patient care services (diagnosis and prescription) for common illnesses.

• focuses on preventive care and disease prevention.

Physician Assistants

• practice medicine under licensed MD/DO.

• make clinical decisions and are responsible for a variety of services.

Medical Laboratory Technicians

• perform diagnostic testing on blood, bodily fluids, and other specimens under supervision of medical technologist.

Occupational Therapists

• assist patients who have developed conditions that disable them developmentally, emotionally, mentally, or physically.

Pharmacy Technicians

• assist pharmacists with duties that do not require expertise or judgement of a licensed pharmacist.

Physical Teherapists

• assist patients in regaining mobility and improving strength and range of motion.

Radiology Technicians

• use various types of imaging equipment to assist provider in diagnosing and treating certain diseases.

Professionalism

• exhibit courteous conscientious and businesslike manner.

• Appropriate Dress (good personal hygiene and work attire)

• Personal Phone Use (take personal calls on break or lunch hours)

• Punctuality (arrive on timely manner)

• Respect for Boundaries (respect personal space and provide effective communication)

• Motivation (intrinsic and extrinsic motivation)

Work Ethic

• set of values based on moral virtues of hard work and diligence.

Integrity

• quality of being honest and having strong moral principles.

Accountability

• be responsible for one’s own actions.

Flexibility

• acclimate to a wide variety of situations.

Open-Mindedness

• willingness to try new things and be considerate of others.

• listen to opponent in a discussion rather than immediately shutting one out due to differences in opinion.

Scope of Practice

• describes duties that can be delegated to medical assistant based on education, training, experience.

• Variables: regulations and policies issued by state medical boards.

Standard of Care

• degree of care or competence expected in a particular circumstance or role.

Certified Health Coach/Patient Navigator

• directs patients through health care system.

Other credentials for medical assistants:

• Certified Phlebotomy Technician (CPT)

• Certified EKG Technician (CET)

• Certified Billing and Coding Specialist (CBCS)

• Certified Electronic Health Records Specialist (CEHRS)

Health Care Licensure

• regulated by state statuses through medical practice acts.

• MD/DO/chiropractic degree is issued upon graduation of medical institute.

• no state required medical assistants to be licensed HOWEVER, some certified medical assistants need to get licensing to perform phlebotomy or EKGs.

Certification

• generally optional.

• to keep credentials current, must perform continuing education units that give them credits toward courses that keep them up to date on procedures and developments in medical field.

• government require certification for Medical Assistants to enter prescriptions into Computerized Physician Order Entry (CPOE) Program.

Accountable Care Organizations (ACOs)

• healthcare delivery model.

• group of physicians, hospitals, and other health care providers come together voluntarily to provide coordinated high-quality care to Medicare patients.

• shares savings it achieves for Medicare program.

Capitation (partial or full)

• healthcare delivery model.

• patients are assigned a per-member, per-month payment based on age, race, sex, lifestyle, medical history, benefit design.

• payment rates are tied to expected usage regardless of patient visits.

• providers have incentive to help patinets avoid high-cost procedures and tests to maximize their compensation.

Globala Budget

• healthcare delivery model.

• fixed total dollar amount paid annyally for all care.

• participating providers can determine how money is spent.

• limit level and rate of increase of health care cost.

Health Maintenance Organization (HMO)

• healthcare delivery model.

• contracts with medical center to provide preventive and acute care for insured person.

• generally require referrals to specialists.

Patient-Centered Medical Home (PCMH)

• healthcare delivery model.

• primary care provider (PCP) coordinates treatment to make sure patient receives required care when and where they need it.

Pay for Performance

• healthcare delivery model.

• compensates providers only if they meet certain measures for quality and efficiency.

Preferred Provider Organization (PPO)

• healthcare delivery model.

• more flexibility than HMO plans.

• can go directly to a specialist without referrals.

• in-network providers usually cost less.

Generalist Provider

• assess wide range of symptoms, diagnoses, and conditions while using a variety of resources to build a treatment plan.

Specialist Provider

• assesses a more specific set of symptoms, diagnoses, and condition.

General Practitioners (GPs)

• MDs who treat acute and chronic illnesses.

• provide preventive care and health education to patients.

• may take holistic approach.

Family Practitioners

• offers care to whole family, from newborns to older adults.

• familiar with range of disorders and diseases.

• preventive care is their primary concern.

Internists

• provide comprehensive care of adults.

• diagnose and treat chronic, long-term conditions.

• offer treatment for common illnesses and preventive care.

• broad understanding of the body and its ailments to diagnose conditions and provide treatment.

Allergists

• evaluate disorders and diseases of immune system.

• includes adverse reactions to medications and food, anaphylaxis, problems related to autoimmune disease, and asthma.

Anesthesiologists

• mange pain.

• use sedation during surgical procedures.

Cardiologists

• specialize in diagnosing and treating diseases or conditions of the heart and blood vessels.

Dermatologists

• specialize in conditions of the skin.

Endocrinlogists

• specialize in hormonal and glandular conditions.

• work with patients who have diabetes mellitus.

Gastroenterologists

• specialize in managing diseases of gastrointestinal tract.

  • stomach

  • intestines

  • esophagus

  • liver

  • pancreas

  • colon

  • rectum

Gynecologists

• specialize in female reproductive system and fertility disorders.

Hematologists

• deals with blood and blood-producing organs.

• work with patients who have anemia, leukemia, lymphoma.

Hepatologists

• specialize in study of body parts such as the liver, biliary tree, gallbladder, and pancreas.

Neonatologists

• care of newborns.

Nephrologists

• kidney care and treating diseases of the kidney.

Obstetricians

• specialize in care of women during and after pregnancy.

Oncologist

• treatment and care of patients who have cancer.

Ophthalmologists

• specialize in eye conditions.

Orthopedists

• specialize in bones, joints, muscles, tendons, and ligaments.

Otolaryngologists

• specialize in ear, nose, and throat.

Neurologists

• specialize in the nervous system.

Pathologists

• specialize in body tissues, blood, urine, and other body fluids to diagnose or treat medical conditions.

Pediatricians

• specialize in newborn, infant, child, and adolescent health care.

Psychiatrists

• specialize in mental disorders and conditions.

Radiologists

• specialize in use of X-rays, ultrasounds, nuclear medicine, computed tomography, and magnetic resonance imaging to detect abnormalities throughout the body.

Urologist

• specialize in disorders of the urinary tract.

Ancillary Services

• adds convenience to patients and increases revenue for organization.

• meet a specific medical need for a specific population.

Urgent Care

• type of ancillary service.

• provide alternative to Emergency Department

• Cost less, have shorter wait time, and conveniently located.

• flexible hours and offer walk-in appointments.

Laboratory Services

• type of ancillary service.

• diagnostic testing on blood, body fluids, and other types of specimens to conclude a diagnosis for the provider.

Diagnostic Imaging

• type of ancillary service.

• machines such as x-ray equipment, ultrasound machines, magnetic resonance imaging (MRI), and computerized tomography (CT) to take images of body parts to further diagnose a condition.

Occupational Therapy

• type of ancillary service.

• assist patients who have conditions that disable them developmentally, emotionally, mentally, or physically.

• helps patient compensate for loss of functions and rebuild to a functional level.

Physical Therapy

• type of ancillary service.

• assists patients in regaining mobility and improving strength and range of motion (often impaired by an accident, injury, or as a result of a disease).

Acupuncture

• alternative therapy.

• pricking of skin/tissues with needles to relieve pain and treat various physical, mental, and emotional conditions.

Chiropractic Medicine

• alternative therapy.

• diagnoses and treats mechanical disorders of the musculoskeletal system, particularly the spine.

Energy Therapy

• alternative therapy.

• calm method of clearing cellular memory through human energy field.

• promoting health, balance, and relaxation.

• centered on idea of connection between physical, emotional, mental states of life found in varous holistic healing techniques.

Dietary Supplements

• alternative therapy.

• contain one or more dietary ingredients (vitamins, minerals, herbs, or botanicals).

• used for its flavor, scent, or potential therapeutic properties.

Advance Beneficiary Notice (ABN)

• insurance form.

• provided to patient when provider believes Medicare will probably not pay for services received.

Allowed Amount

• maximum amount a third party payer will pay for a particular procedure or service.

Copayment

• amount of money that is payed at the time of medical services.

Coinsurance

• insurance policy provision.

• found in medical insurance whereby policyholder and insurance company share the cost of covered losses in a specified ratio, such as 80:20.

Deductible

• specific amount of money a patient must pay out of pocket before the insurance carrier begins paying.

Explanation of Benefits

• statement from insurance carrier detailing what was paid, denied, or reduced in payment.

• contains information about amounts applied to deductible, coinsurance, and allowed amounts.

Participating Provider (PAR)

• providers who agree to write off difference between amount charged by the provider and the approved fee established by insurer.

Medicare

• type of insurance plan.

• covers patients age 65+ by:

  • Part A (hospitalization)

  • Part B (routine medical office visits)

Tricare

• type of insurance plan.

• dependents of military personnel receives treatments from civilian providers at the expense of the federal government.

CHAMPVA

• type of insurance plan.

• covers surviving spouses and dependent children of veterans who died as a result of service-related disabilities.

Medicaid

• type of insurance plan.

• provides health insurance to medically indigent population through a cost-sharing program between federal and state governments for those who meet specific eligibility criteria.

Managed Care

• type of insurance plan.

• umbrella term for plans that provide health care in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals.

Workers’ Compensation

• type of insurance plan.

• protects wage earners against the loss of wages and cost of medical care resulting form an occuaptional accident or disease as long as the employee is not proven negligent.

Private Insurance Plans

• Blue Cross/Blue Shield

  • oldest and largest system of independent health insurers

• Aetna

• United Healthcare

• offers 2 managed care models

  • PPO

    • flexibility in plan

  • HMO

    • comprehensive and require insured to choose a PCP (primary care provider)

CMS-1500 Form

• used by health care payers for claims submitted by provider or supplier.

• 33 blocks of items divided into 3 sections.

  • Section 1: Carrier Block

  • Section 2: Patient/Insured Section

  • Section 3: Physician/Supplier Section

Section 1 of CMS-1500 Form (Carrier Block)

• contains address of insurance carrier.

• located at the top of the form.

Section 2 of CMS-1500 Form (Patient/Insured Section)

• contains information about the patient or insured (if other than the patient).

• includes boxes 1-13.

• basic information about patient.

• determining which plain is primary and which is secondary (block 11, if the patient has 2).

Section 3 of CMS-1500 Form (Physician/Supplier Section)

• contains information about physician or supplier.

• includes boxes 14-33.

Administrative Simplification Compliance Act (ASCA)

• require that claims to Medicare be transmitted electronically