MAS 115Medical Office Administration

Chapters 1 ~ 3

Review for Exam

Some advantages of Managed Care include:

• 100% coverage of approved treatment with very little out-of-pocket expense

• People are more likely to get preventative care since their insurance is pre-paid

Capitation is:

• A fee ‘per head,’ usually per month, paid to the physician by a managed care insurance company

Which type of medical practice has the advantage of shared liability?

• Solo practice

• Associate practice

• Group practice

They are two types of “permission” from patients to share PHI

• Consent ~ for routine transactions

• Authorization ~ for special transactions

Examples of bioethical issues today include:

• IVF and other reproductive technologies, stem cell research, cloning, surrogacy, euthanasia

What’s malpractice?

• Literally “bad practice”

• It means carelessness or negligence of a professional

Bonding is

• Insurance against embezzlement

Can you name six ways an administrative medical assistant can protect their patient’s PHI?

Name some good characteristics that demonstrate a professional

attitude:• Initiative• Honesty• Respectful• Dependable• Decisive• Accurate• Confidential• Ethical

Credentialing is

• Review of the physician’s curriculum vitae (resume); checking up on hospital, practice history and peer references; and often includes an oral interview

Some examples of Managed Care Organizations include:

• HMO

• PPO

• IPA

• EPO

• POS

HIPAA is

• The Health Insurance Portability & Accountability Act

• Regulates the rules regarding privacy of protected health information (PHI)

Medical Practice Acts are

• State acts that regulate the requirements for obtaining a medical license

• Designed to protect the public from “quackery”

Tort is

• A tort is when one person causes injury to another person

Important interpersonal skills to have are:

• Observing

• Showing interest, concern

• Watching your tone of voice

• Empathy

• Initiative

• Teamwork

• LISTENING!

Three steps in coping with stress include:

1) Identify the cause of stress

2) Evaluate the situation ~ what can you do about it?

3) Confront the problem ~ Make a decision and do it!

Five stages of dying (in order) are:

• Denial

• Anger

• Bargaining

• Depression

• Acceptance

Hospice is

• Medical care and support for patients and families during terminal illness

HIPAA’s security rule covers:

• Physical and technical safeguards

• Policies, procedures, documentation requirements

• Risk analysis and management

• Administrative safeguards

Who “owns” the medical record?

• The physician (or the health care organization itself)

Respondeat Superior means:

• Literally “let the master answer”

• Figuratively it means that an employer can be held liable for the actions of its employees

You do NOT need authorization to share PHI under these conditions:

• In emergencies

• When mandated by the State to report communicable diseases or concerning conditions

• When subpoenaed by a court of law

• Federally-funded programs automatically have authorization to receive certain PHI

An authorization is

• “Special” permission from a patient to share certain PHI with certain people regarding a certain timeframe

A Consent is:

• “Routine” permission from a patient to share information regarding treatment, payment or other routine health care operations

What’s a Compliance Officer?

• A person who oversees and monitors an organization’s HIPAA compliance plan

Misfeasance means

• Lawful or proper treatment but done incorrectly

Who oversees the Medical Practice Act?

• Each State Board of Medical Examiners oversees its own State Medical Practice Act

HIPAA’s privacy rule defines patient’s rights which include:

• Patient’s have a right to receive notice about how an organization is sharing their PHI

• They have a right to access their own records• They have a right to ask for amendment to their

own records• They have a right to ask a health care

organization for an “accounting” – when and to whom were their records released?

• They have a right to restrict disclosures of information

What’s the Good Samaritan Law?

• State laws (they vary) which protect off-duty health care workers and others from liability when responding to emergencies

• It’s intended to ENcourage health care workers to help…without fear of being sued

• No duty = no contract and no 4D’s of negligence• HOWEVER ~ actions must be considered

“prudent,” not reckless; nor can doctor “charge a fee” for service

Nonfeasance means

• Failure to treat when there was a duty to do so

Types of Contracts:

• Expressed Contract ~ Written or verbal agreement

• Implied Contract ~ An agreement deduced from the situation (emergencies) or from the patient’s behavior

• NOTE: No Contract exists during a “Good Samaritan” action (p. 79)

What are some alternatives to litigation?

• Screening panel– A physician review panel; advisory but cannot

bar litigation

• Arbitration – Agreed upon before treatment; in some States

this can be a binding decision

• No-fault insurance – “Injured person is compensated without

regard to fault” (p. 78)

What are some “defenses” the physician may use if sued?

• Contributory negligence ~ the patient was in some way responsible for his or her own injuries (fully or partially)

• Assumption of risk ~ the patient was informed of the risks of treatment but chose to consent anyway

• Statute of Limitations ~ the time limit to take legal actions has passed/expired

Malfeasance means

• Improper or unlawful treatment

The 4D’s

• Are:– Duty– Dereliction (of duty)– Direct Cause– Damages

• All four are necessary to prove negligence

Some ways you can reduce litigation for your office/employer:

• Obey the LAW!• Work within the scope of your training and

be careful• Don’t (assume and then) admit fault• Don’t make promises• Don’t practice medicine without a license!• Keep timely, accurate records• AND ~ LISTEN and COMMUNICATE

Examples of intentional torts include:

• Assault & Battery*• Invasion of Privacy*• Defamation of Character• Libel or Slander• False Imprisonment*• Fraud• *MY NOTE: Some of these can be “negligent”

torts as well – depends on “intent” of the accused

Examples of negligent (or UNintentional) torts might include:

• Accidentally administering incorrect dose• Accidentally faxing PHI to wrong number• Accidentally documenting information in the

wrong chart…• Negligence occurs when we do not “behave in

the way a prudent person who is similarly educated and trained would behave under comparable circumstances.” (p. 75)

• MY NOTE: In health care, most lawsuits are regarding UNintentional torts

What’s “Criminal Negligence?”

• Reckless disregard for, or indifference to, the welfare of a patient

What kind of comments could be perceived as “Promise to cure?”

• “You’ll be just fine…”

• “Dr. Smith will fix you right up…”

What is “stress?”

• Physical and psychological tension, caused by both “good” and “bad” events in our lives

It’s when a physician is not available when the patient seeks

help

• Abandonment

• Today, doctors must be careful to communicate with patients – terminate the contract properly, have ‘coverage’ available for patients when they are ill or on vacation, etc.

Reasons a physician might terminate a contract with patient:

• Failure to pay for appointments

• Failure to appear for appointments

• Failure to follow medical advice

How should a patient be informed their contract with physician is terminated?

• In writing• Mailed certified with return receipt• Letter should state reason, and allow enough

time for patient to find new doc• Copy of letter and signed receipt should be filed

in patient’s chart as “proof” of proper termination• PURPOSE: To avoid charge of abandonment

What’s an advance directive?

• Legal form detailing the desires of the patient for procedures to either be performed or withheld when death is imminent

Examples of advance directives:

• Living Will

• Health Care Power of Attorney

• Medical Directive

• Values History Form

• Health Care Proxy

• DNR (Do Not Resuscitate)

• Donor/Anatomical Gift Form

Some “advantages” for the patient with Traditional Care insurance

(versus Managed Care):

• Patients feel they have more choice – they can see any doctor, any time, as often as they want (no ‘network’)

• No pre-authorization is required so there are no delays in treatment, referrals, getting medications

What is “Informed Consent”

• Remember it has two parts – “Informed” and “Consent”

• Informed ~ doctor explains risks, benefits, alternatives of recommended treatment and answers any questions

• Consent ~ patient agrees to treatment after being informed, often “signing” a formal consent agreement

Special rules about “Minors”

• States have varying laws about minors• Emancipated Minors can personally

consent to treatment (p. 80)• “Mature minor” is usually over 14 years of

age and can often consent to medical/surgical treatment without parental consent

• Reproductive Health issues: Abortion, pregnant unmarried minors – rules vary by State

Sources of stress include:

• Good– Marriage– Birth of a baby– Better Job– Moving

• Bad– Divorce– Death– Loss of job– Health issues

What’s a gatekeeper?

• A primary care doctor who oversees the patient’s plan of care

• This position is designed to help Managed Care control costs by scrutinizing referrals, pre-authorizing tests or drugs, etc.

Subpoena is

• Court order to appear

• Subpoena duces tecum is– Court order to appear with records

PHI stands for

• Protected Health Information

• It includes personal identification and patient’s health information

Some reasons doctors are more likely to be sued today:

• Well educated public expects the best care regardless of ability to pay; when they don’t get it, they may sue

• Different “relationship” with doctors today; not held on a pedestal; more like “equal partners” in health care. Patients more like to question, compare (and sue) doctor

• Bioethical issues generate lawsuits – new, untested legal ground = lawsuits

• Managed care can cause delays in approvals, testing, diagnosis = lawsuits

What’s the difference between an “authorization” and a “pre-

authorization?• An authorization is special patient

permission to share certain PHI• A pre-authorization is a request sent to

managed care insurance for the purpose of gaining their agreement to pay for certain services, testing, drugs, etc. If they “approve” they will pay; if they do not approve, they will not pay.

What’s the difference between a consent and an informed consent?

• Consent is permission from a patient to share routine health care information with insurance companies, other people involved in their care

• Informed consent is when a provider ‘informs’ patient of risks, benefits, alternatives to treatment, and then the patient gives (usually written) consent for the treatment as described

Some reasons for the rise in health care costs today include:

• Increased cost of a medical education• Increased lawsuits cause increase in

medical malpractice insurance• Longer life expectancy = more people with

chronic health issues = increased costs• Increased technology = increased

specialization = higher cost for personnel• Docs over-prescribing, over-testing to

reduce liability = wasteful = higher costs

“Think with empathy, act through ___________________”?

SERVICE!