Henderson Exam 3 Study Guide - Chapters 6 & 7

Vocabulary terms and definitions covering healthcare law, medical ethics, operations, credentialing, practice management, insurance models, and federal health programs for Exam 3 Chapters 6 & 7.

Tort

A civil wrong caused by an action or failure to act that harms another person and may lead to a lawsuit for damages.

Negligence

Failing to use reasonable care.

Malpractice

Professional negligence in which a healthcare worker fails to meet the expected professional standard and causes harm.

Duty

The first element of negligence; establishing that a legal responsibility existed.

Breach

The second element of negligence; failure to meet the expected standard of care.

Direct Cause

The third element of negligence; establishing that the failure to meet standard care directly caused the patient's injury.

Damages

The fourth element of negligence; proof that the patient suffered an actual injury or loss.

Compensatory Damages

Financial awards that repay actual losses, such as medical bills, lost income, pain, or disability.

Punitive Damages

Financial awards designed to punish especially intentional, reckless, or wrongful behavior.

Nominal Damages

A small financial award given when legal fault is established but little to no actual harm occurred.

Res Ipsa Loquitur

"The thing speaks for itself" - a legal rule applied when an error is so obvious that the event itself strongly indicates negligence.

Respondeat Superior

"Let the master answer" - a rule stating an employer may be held responsible for an employee's actions within the scope of employment.

Statute of Limitations

The law setting time limits to file a lawsuit, which under the discovery rule may begin when harm is discovered rather than when it occurred.

Mediation

A dispute resolution process where a neutral third party helps both sides communicate and create their own agreement without deciding the case.

Arbitration

A dispute resolution process where a neutral third party hears both sides and makes a binding decision.

Risk Management

Healthcare processes designed to prevent patient harm and reduce errors and liability through safe practices, training, policies, communication, and documentation.

Comparative Negligence

A legal principle where the patient's own actions contributed to the injury, reducing compensation based on their percentage of fault.

Contributory Negligence

A legal principle where any degree of patient fault in causing their injury can completely bar them from recovering damages.

Assumption of Risk

A legal defense applied when a patient was aware of potential dangers and voluntarily chose to proceed anyway.

Good Samaritan Laws

Laws protecting individuals who provide reasonable emergency assistance without a prior duty to act, provided they act within their skills and not recklessly.

Scope of Practice

The legal and professional limits defining the tasks and care a healthcare worker is qualified and legally permitted to perform.

Malfeasance

The performance of a completely wrong or illegal act.

Nonfeasance

The failure to act or perform a required duty when action was necessary.

Misfeasance

The improper performance of a lawful or expected action.

Physician

A fully licensed Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).

Specialist

A physician who has completed advanced clinical training in a specific medical specialty field.

Nonphysician Provider

A healthcare provider, such as a Nurse Practitioner (NP) or Physician Assistant (PA), authorized to deliver major medical services within legal limits.

Allied Health Professional

A healthcare worker who supports and complements direct patient clinical care or administrative office operations.

Credentialing

The verification process of a practitioner's education, training, licensure, certifications, work experience, and professional background.

Certification

Official documentation from a professional organization confirming an individual has met required qualifications through examination and training.

Licensing

Legal authorization granted by a government body to practice a specific profession.

Registration

Listing on an official registry maintained by a professional organization following exam completion or qualification verification.

Solo Practice

A medical practice structure where a single healthcare provider owns and operates the office.

Sole Proprietorship

A business model where a single owner owns the practice and has authority to employ additional providers and support staff.

Associate Practice

A practice arrangement where multiple physicians share facility space, staff, and overhead expenses while maintaining separate liabilities and practice finances.

Group Practice

A medical business model where three or more physicians share facilities, staff, administrative resources, liabilities, and potential profits.

Deductible

The fixed out-of-pocket amount a policyholder must pay toward medical costs before their insurance begins paying for covered services.

Copay (Copayment)

A set dollar fee paid by the patient at the time of service for a specific medical visit or treatment.

Coinsurance

The percentage split of allowed healthcare costs paid by the patient after reaching their deductible.

Third-Party Payer

An entity, such as a health insurance company or government program, that pays medical bills on behalf of a patient.

Gatekeeper

A Primary Care Physician (PCP) in an HMO model responsible for directing overall patient care and authorizing specialist referrals.

Indemnity Plan

A fee-for-service health insurance plan offering unrestricted choice of providers without requiring primary care referrals, typically at higher premiums.

HMO (Health Maintenance Organization)

A managed care option requiring in-network care, selection of a Primary Care Physician, and specialist referrals in exchange for lower costs.

PPO (Preferred Provider Organization)

A managed care option providing network flexibility, out-of-network coverage options, and direct access to specialists without primary care referrals.

POS (Point of Service) Plan

A hybrid managed care model requiring a Primary Care Physician for coordinated referrals while permitting out-of-network options at elevated costs.

Medicare

A federally funded health insurance coverage program primarily serving seniors aged 65 and older and specific younger individuals with qualified disabilities.

Medicaid

A combined state and federal assistance program providing medical coverage based on financial income limits and qualifying conditions.

TRICARE

A federal health benefit program designed for active-duty military personnel, military retirees, and eligible dependents.

CHAMPVA

A VA benefits coverage program tailored for qualifying spouses, dependents, and survivors of veterans ineligible for TRICARE.

Medicare Part A

The hospital insurance portion of Medicare covering inpatient stays, hospital care, and hospice costs.

Medicare Part B

The medical insurance portion of Medicare covering outpatient care, doctor visits, and preventative care.

Medicare Part C

Medicare Advantage plans offered by approved private insurance companies to deliver Part A and Part B coverage.

Medicare Part D

The outpatient prescription drug coverage component of Medicare.

Incident-to Billing

A practice method where outpatient services performed by nonphysician providers are billed under the supervising physician's billing code.