1.2: Healthcare Fundamentals

Medical assistants must function as team members.
They need to work alongside medical providers.
Knowledge required:
- Specialties
- Allied health professionals
- Healthcare delivery models
- Basic insurance

Medical Doctors (MD)
- Diagnose illness
- Provide treatments
- Perform procedures
- Write prescriptions (drugs or surgery)
Osteopathic Providers (DO)
- Use modern medicine techniques and surgical procedures
- Osteopathic manipulative therapy
Nurse Practitioners (NP)
- Diagnose and prescribe medications
- Focus on preventative care and disease prevention.
Physician Assistant (PA)
- Practices medicine under the direction and supervision of a licensed MD or DO.
- Able to make clinical decisions.

Medical Laboratory Technician
- Performs testing on blood, body fluids, and other specimens.
Pharmacy Technician
- Assists pharmacists with duties.
Radiology Technician
- Uses imaging equipment to assist providers in diagnosing and treating diseases.

Professionalism
- Skills, behavior, and appropriate judgment that represents the best qualities of a person in specific professions.
Appropriate dress and hygiene
- Avoid perfumes and colognes
- Conservative makeup
- Clean, unpolished nails at reasonable length
Punctuality
- Arrive to work on time.
- Have good time management
Personal phone use
- Only take personal calls during breaks or lunch hours
- Never respond to text messages while working with patients
- Put on vibrate
Integrity
- Be honest, have strong moral principles
Accountability
- Be responsible for your own actions
Flexibility
- Adjust to schedule changes
- Assist others, work as a team
- Never say "That's not my job”
Open-mindedness
- Try new things, increase skills
- Be open to discussions and listen

Accountable Care Organizations (ACO)
- Groups of physicians, hospitals, and care providers come together voluntarily to provide quality care to Medicare patients.
Patient-Centered Medical Home (PCMH)
- Care delivery model - primary care provider (PCP) coordinates treatment to make sure patients receive required care.
Health Maintenance Organization (HMO)
- Plan contracts with groups of providers and facilities for preventative and acute care for patients.
- HMOs require referrals to specialists, precertification, and preauthorization for hospital admissions, outpatient procedures, and treatments.
Preferred Provider Organization (PPO)
- Plan has more flexibility than an HMO.
- Patient is not required to have a PCP and can go directly to a specialist without referrals.
- In-network and out-of-network providers.

Long-term care: Nursing Homes and Assisted Living
- Residents require healthcare on a regular basis.
- Frail, elderly & disabled
Hospice care
- Patients with less than six months to live
- Terminal conditions
Palliative Care
- Only relieving pain
Ambulatory (Walk-in)
- Physician offices/Clinics
- Urgent Care centers
- Hospitals/Emergency Department
- Surgical Centers

General providers
- Able to assess a wide range of symptoms
- Diagnose and build treatment plans.
Specialist providers
- Assess more specific sets of symptoms, diagnoses, and conditions.

General Practitioners (GP)
- Medical doctors who treat acute and chronic illnesses and provide preventative care and health education.
- May take a holistic approach to healing.
Internists
- Diagnosing and treating chronic conditions.
- Offer treatment for common illnesses and preventative care.

Cardiologists
- Specializes in conditions of the heart and blood vessels.
Dermatologists
- Specializes in conditions of the skin.
Endocrinologists
- Specializes in hormonal and glandular conditions, Diabetes, thyroid.
Gastroenterologists
- Specializes in diseases of the gastrointestinal tract; stomach, intestines, esophagus, liver, pancreas, colon, rectum.
Gynecologists
- Specialize in the female reproductive system.
Nephrologists
- Specializes in kidney care and disorders of the kidneys.
Obstetricians
- Care of women during and after pregnancy.
Oncologists
- Specializes in cancer treatments.
Ophthalmologists
- Specialize in eye conditions.
Orthopedists
- Specialize in bones, joints, muscles, tendons, and ligaments.
Otolaryngologists/Otorhinolaryngologist (ENT)
- Specializes in ear, nose, and throat.

Government plans
- Medicare - patients over 65 and older, Part A (hospitalization), Part B (medical office visits), Part D (medications)
- Medicaid - medically indigent/low income
- Tricare - active duty service and family members
- (CHAMPVA) - Veterans Affairs
Private plans
- Group
- Individual
- Examples: Blue Cross, Humana, Aetna, Cigna
Worker’s compensation

Allowed amount
- Maximum amount a third-party (insurance) will pay for a procedure or service.
Copay
- A set amount of money that is paid by the patient at the time of service.
Coinsurance
- The policyholder and insurance carrier share costs, 80/20
Deductible
- Amount of money paid out of pocket before the insurance carrier begins paying.

Submitted by:
- Direct billing - insurance carrier allows the provider to submit directly to the insurance company electronically.
- Clearinghouse - allows provider to submit all insurance claims using software. Clearinghouse audits, sorts claims, and sends them to the appropriate insurance company.
Must be sent timely.
- For Medicare and Medicaid claims - the invoice cannot exceed 12 months from service.

Ambulatory
- Able to walk.
Managed care
- A term for medical plans that provide health care in return for preset scheduled payments coordinated through a network of providers and hospitals.
Osteopathic
- A type of medical care based on how the musculoskeletal system affects other body parts and uses various manipulative methods along with conventional medical, pharmacological, and other therapeutic procedures.
Professionalism
- The skills, behavior, and appropriate judgment that represent the best qualities of a person in a specific profession.
Work ethic
- A set of values based on the moral virtues of hard work and diligence.