HSTP Unit 2

What is a healthcare delivery system?

The complete framework through which care is accessed, provided, coordinated, and funded.

Who are considered professionals in healthcare delivery systems?

Trained healthcare staff such as physicians, nurses, and medical assistants.

What types of facilities are included in healthcare delivery systems?

Hospitals, urgent care centers, primary care and specialty clinics, mobile health clinics, rehab centers, hospice, skilled nursing facilities, and long-term care centers.

What are the goals of healthcare delivery systems?

Improve access to care and quality of care, enhance patient experience, and reduce per capita costs.

What does 'patient-centered care' prioritize?

Patient-centered care prioritizes continuity, satisfaction, and active patient engagement in decision-making.

What is a Patient-Centered Medical Home (PCMH)?

A team-based care model led by a primary care provider to ensure comprehensive, continuous, and coordinated care.

What does holistic care refer to in a PCMH?

Treating the patient as a whole person, addressing physical, mental, emotional, social, and spiritual needs.

What is inpatient care?

Medical treatment provided to a patient who is formally admitted to a healthcare facility and requires an overnight stay.

What is outpatient care?

Medical services provided to a patient who receives treatment without being admitted for an overnight stay.

What is the purpose of urgent care centers?

To provide immediate, non-emergency care for acute injuries and illnesses that require prompt attention.

What do primary care clinics focus on?

Routine wellness, preventative care, health screenings, managing chronic conditions, and responding to acute stable injuries or illnesses.

What are the two types of rehab centers?

Physical rehabilitation centers and addiction or substance abuse rehab facilities.

What is the focus of hospice care?

Providing palliative treatment, comfort, and emotional support to terminally ill patients with a life expectancy of less than six months.

What is palliative care?

Relieving pain, symptoms, and stress to improve quality of life for patients and their families, regardless of age or life stage.

What are skilled nursing facilities?

Inpatient residential care facilities providing 24-hour medical supervision and skilled nursing care.

What is the role of third-party payers?

Organizations other than the patient or healthcare provider that pay or insure medical expenses on a person's behalf.

What does Medicare cover?

Health insurance for seniors 65+ and disabled individuals, covering hospital, outpatient, and prescription drug services.

What is Medicaid?

A program that provides health coverage for low-income individuals, funded by federal and state governments.

What is the difference between in-network and out-of-network providers?

In-network providers have contracts with insurance companies for discounted rates, while out-of-network providers do not, leading to higher costs.

What are Health Maintenance Organizations (HMOs)?

Managed care models requiring members to select a primary care provider and obtain referrals for specialists.

What are Preferred Provider Organizations (PPOs)?

Managed care models allowing members to visit any provider directly without referrals, often at higher out-of-pocket costs.

What are employer contributions in health insurance?

The portion of an employee's health insurance premium paid directly by their company.

What is an insurance premium?

The fixed, recurring fee paid to a health insurance company to maintain active coverage.

What is a deductible in health insurance?

The specified amount a patient must pay out-of-pocket for covered medical services before insurance begins paying.

What are copayments?

Fixed, flat dollar amounts that a patient pays out-of-pocket at the time of a medical service or visit.

What is a copayment?

A fixed, flat dollar amount that a patient pays out-of-pocket at the time of a medical service or visit.

What is coinsurance?

A percentage-based split of the total covered medical cost that the patient pays after meeting their deductible.

What does max out-of-pocket refer to?

The absolute most a patient will have to pay for covered, in-network medical services during the year.

What is private pay in healthcare?

A billing model where the patient pays the provider directly for medical services, bypassing insurance coverage.

What is the fee-for-service payment model?

A model that pays providers based on the volume of services delivered, reimbursing a set fee for each service regardless of outcomes.

What are incentive models in healthcare?

Payment models that tie financial compensation to the quality, efficiency, and effectiveness of care.

What is an Accountable Care Organization (ACO)?

A voluntary network of healthcare providers that coordinate care for a specific patient population, sharing in financial savings if they meet quality benchmarks.

What is the first step in the patient check-in process?

Verifying the patient's full name and date of birth.

What distinguishes new patients from established patients?

New patients have never received services from the practice or it's been over three years since their last visit.

What is the purpose of patient portals?

To allow patients to access their health records, view visit notes, educational materials, lab results, and schedule follow-up appointments.

What information is included in the demographics form during check-in?

Full legal name, date of birth, current mailing address, phone number, marital status, and insurance information.

What is the Assignment of Benefits form?

A form that allows the office to bill insurance directly for reimbursement.

What does the Notice of Privacy Practices (NPP) explain?

It explains patients' rights under HIPAA and must be included in the patient's chart.

What is Protected Health Information (PHI)?

Any health data that can be linked to a specific individual, protected under HIPAA.

What is an encounter form or 'superbill'?

An itemized charge slip detailing clinical services provided during a patient visit, bridging clinical documentation and financial systems.

What information is required on the encounter form?

Patient information, provider information, visit specifics, diagnosis codes (ICD-10), procedure codes (CPT/HCPCS), and financial summary.

What must a provider do after a patient visit regarding the encounter form?

Indicate the level of services provided and sign the form.

What is the purpose of the Medical Record Release/Authorization form?

To request that a healthcare provider release the patient's medical records to the patient or a third party.

What is the Confidential Communication Form?

A form that authorizes the organization to communicate with the patient in specified ways and release PHI to designated individuals.

What is the Consent for Treatment?

A form that allows providers to perform diagnostic procedures and necessary medical care.

What should be done if a patient refuses to sign the NPP?

Document that the patient was provided with a copy of the form and had the content explained.

What is the significance of verifying the patient's insurance information during check-in?

To ensure accurate billing and prevent fraud by matching the patient's medical record with their insurance plan.

What is the role of the medical assistant (MA) during patient check-in?

To confirm demographic information and assist in the check-in process for both new and established patients.

What must the provider do before a patient checks out?

Sign the encounter form.

How is the encounter form typically signed?

Electronically, but some facilities still use paper forms.

What does the MA do during patient checkout?

Reviews comments such as referrals or the need for follow-up.

What should the MA assist the patient with during checkout?

Scheduling follow-up appointments, specialist referrals, labs, or imaging.

What is required before sharing patient information with a specialist?

The patient must sign a release of information form.

What should be verified regarding specialist referrals?

That the referral is in-network for the patient.

What is adjudication in the context of patient checkout?

How the payer determines how the claim should be paid based on insurance plan details.

What are the possible adjudication options?

Payment in full, partial payment, pending status, or payment denied.

What is real-time adjudication?

An automated tool for instant reimbursement decisions while the patient is present.

What does the after visit summary (AVS) contain?

Information about medications, follow-up appointments, provider orders, instructions, and educational resources.

What should the MA highlight in the AVS?

Any new medications and clarify new medication instructions.

What is the first step in the patient scheduling process?

Verify the patient's full name, date of birth, and phone number.

What is the best practice for scheduling acute illness visits?

Schedule patients with same-day appointments.

What should be done after scheduling an appointment?

Confirm the appointment day and time by repeating it to the patient.

What is the purpose of a scheduling grid or template?

To outline a provider's availability and block times they're unavailable.

What is stream scheduling?

A system where each patient has a specific appointment time throughout the day.

What is wave scheduling?

Booking several patients at the same time and seeing them in the order they arrive.

What is double booking in scheduling?

Scheduling two or more patients for the same time slot, each needing the entire allotted time.

What should be done if a patient needs to cancel an appointment?

Use the abbreviation 'CAN' for cancel.

What does 'F/u' stand for in scheduling abbreviations?

Follow-up appointment.

What is the abbreviation for 'no-show patient'?

N/S.

What does 'Rx' represent in scheduling abbreviations?

Prescription.

What is the significance of accuracy in scheduling?

All appointment information must be clear and understandable, as it becomes part of the legal medical record.

What should be done if follow-up care cannot be coordinated at the time of the visit?

Highlight information about who the patient should call.

What is the purpose of confirming appointment details with the patient?

To ensure they are aware of the date, time, and any balance due.

What does 'Pt / pt' stand for?

Patient.

What is the abbreviation for 'electrocardiogram'?

ECG.

What does 'N&V' stand for?

Nausea and vomiting.

What is cluster scheduling?

A method where physicians group similar appointments into scheduled blocks for efficiency.

What is an example of cluster scheduling in pediatrics?

A pediatrician may only offer sports physicals on Mondays and Wednesdays from 1500-1800.

What is a disadvantage of cluster scheduling?

Limited flexibility in scheduling and may not accommodate patient preferences.

What are open office hours?

A system where patients are seen in the order they arrive without scheduled appointments.

What is an advantage of open office hours?

Eliminates the risk of missed or canceled appointments.

What is a disadvantage of open office hours?

Unpredictable patient volume can lead to long wait times.

What characterizes routine visits?

They cover a wide variety of simple patient concerns, typically lasting 10-30 minutes.

What defines acute illness visits?

Visits for patients with rapid onset of unexpected sickness needing same-day appointments.

What should you advise acutely ill patients who are worked into a full schedule?

They may experience a slight wait but will be seen as soon as possible.

What types of patients can be seen during emergency visits?

Patients with minor emergencies like severe pain or high fever.

What should be done for patients with major emergencies?

They should be directed to the emergency room immediately.

How should staff handle wait times and delays?

Keep patients informed with professional explanations and apologize for delays.

What is a no-show?

When a patient misses an appointment without calling to cancel.

What should the MA do when a patient no-shows?

Follow up with the patient, try to reschedule, and document the incident.

What is the procedure for cancellations?

Patients provide advanced notification and the MA should offer to reschedule.

What should be done for unexpected visitors?

Assess if they are in distress and inform the provider immediately.

What is a consultation in medical terms?

When a primary care provider seeks guidance from another physician.

Who is the referring physician?

The physician who requests a consultation.

What is a consultant?

The physician who receives the consultation request.

What should the MA verify before scheduling referrals?

Ensure that consultations and referrals are in-network for insurance coverage.

What is the sitting position used for?

Physical exams of the head, neck, chest, back, and to ease difficulty breathing.

What is the prone position used for?

Examinations or surgeries of the neck, back, and to improve oxygenation in critically ill patients.

What is the supine position used for?

Physical assessments of the anterior body and procedures requiring access to the front.

What is the lithotomy position commonly used for?

Gynecologic procedures like pelvic exams and childbirth.