AH 204 Chap 3 10th edit.pptx

Because learning changes everything. ® Chapter 03 Working in Health Care Law & Ethics for Health Professions TENTH EDITION Karen Judson, Carlene Harrison, and Tammy Albright © McGraw Hill LLC. All rights reserved. No reproduction or distribution without the prior writ...

Because learning changes everything. ® Chapter 03 Working in Health Care Law & Ethics for Health Professions TENTH EDITION Karen Judson, Carlene Harrison, and Tammy Albright © McGraw Hill LLC. All rights reserved. No reproduction or distribution without the prior written consent of McGraw Hill LLC.  Learning Outcomes 3.1 Define licensure, certification, registration, and scope of practice as they apply to requirements for individuals working in health care. 3.2 Define accreditation as it applies to health care facilities, managed care organizations (MCOs), and educational programs. 3.3 Summarize the purpose and scope of authority for practice acts and professional state boards in health care. 3.4 Identify the major business aspects of health care. 3.5 Distinguish between the different types of MCOs. © McGraw Hill, LLC 2  Licensure Mandatory credentialing process established by law, usually at the state level, that grants the right to practice certain skills and endeavors. Required in every state for physicians, nurses, and other health care practitioners. Licenses for health care professionals to practice can be revoked (canceled) or suspended (temporarily recalled) in certain circumstances. Sexual Misconduct Medication Violations Substance Abuse Unethical Behavior Professional Discipline Poor Documentation Fraud Unlicensed Practice Patient Abuse Boundary Violations © McGraw Hill, LLC 3  Obtaining a License in Another State Reciprocity: the process by which a professional license obtained in one state may be accepted as valid in other states by prior agreement without re-examination. Endorsement: is another process by which a license may be awarded based on individual credentials judged to be licensing requirements in the new state of residence. © McGraw Hill, LLC 4  Certification A voluntary credentialing process whereby applicants who meet specific requirements may receive a certificate. Usually, a specific education and a national exam is required. Example: a CMA/AAMA (Certified Medical Assistant / American Association of Medical Assistants) requires graduation from an accredited program and success in a national exam. © McGraw Hill, LLC 5  Registration Historically was a credentialing procedure whereby one’s name was listed on a register as having paid a fee and/or met certain educational criteria within a profession. Today it is like the certification process. Example: Registered Health Information Technician (RHIT) requires graduation from an accredited program and success in a national exam (American Health Information Management Association). © McGraw Hill, LLC 6  Scope of Practice The duties/procedures that a person may and may not perform under the auspices of a specific health care practitioner's license. Duties determined by each state’s laws, regulations, educational requirements, and licensing bodies. © McGraw Hill, LLC 7  Accreditation Official authorization or approval for an organization conforming to specific standards—usually voluntary. Health care organizations such as hospitals, patient care facilities, and health plans are accredited. Health care educational organizations are accredited. © McGraw Hill, LLC 8  Joint Commission Accreditation The organization is known as the TJC. Major accreditation agency for: Variety of hospitals. Long-term care facilities (for example, nursing homes and assisted living). Clinical laboratories. Ambulatory care: outpatient surgery, rehabilitation centers, group practices home care. © McGraw Hill, LLC 9  Educational Program Accreditation Accrediting agencies for health care education are national associations. An entire school or individual healthcare education program's may be accredited. Evaluate effectiveness of an educational program. Does the program meet broad and specific professional standards? Appropriate laboratory and internship experiences. Are students able to pass licensure or certification exams? © McGraw Hill, LLC 10  Practice Acts In all 50 states, practice acts have been established by statute to govern the practice of health care practitioners. Professional boards to protect health, safety and welfare of health care consumers. Primary mandates of practice acts are to: Define practice of individual health professions in each state. Explain requirements and methods for licensure. Establish licensing boards. Establish grounds for suspension or revocation of license. Give conditions for license renewal. © McGraw Hill, LLC 11  Business Aspects of Health Care One of the few major industries where most costs are paid by third party payers. Four types: For profit. Not for profit. Governmental health care providers. Companies that make health care products. © McGraw Hill, LLC 12  Managed Care Organizations A system in which corporations link the financing, administration, and delivery of health care services that are combined to provide medical services to subscribers for a specific fee. May take the form of: Contracted fee schedules. Percentage of fees. Capitation. © McGraw Hill, LLC 13  Important Managed Care Terminology Managed care measures: Coinsurance Copayment Deductible Formularies Utilization Review Plan approved costs © McGraw Hill, LLC 14  Traditional Managed Care Businesses Health maintenance organizations. Independent practice associations. Preferred provider organizations. Physician-hospital organizations. Exclusive provider organizations. Variety of access plans. Other variations: HRA HSA HDHP PCMH © McGraw Hill, LLC 15  Variations of Managed Care Patient centered medical home (PCMH) is practice specific. Accountable care organization (ACO) requires coordination and affiliation among multiple practices. Both offer incentives to providers to improve care. © McGraw Hill, LLC 16  End of Main Content Because learning changes everything. ® www.mheducation.com © McGraw Hill LLC. All rights reserved. No reproduction or distribution without the prior written consent of McGraw Hill LLC.