Health Systems Final PDF

standardsofcareholdaproviderofexceptional skin orknowledge toacting aswould a reasonable rprudentproviderpossessing MODULE 4...

standardsofcareholdaproviderofexceptional skin orknowledge toacting aswould a reasonable rprudentproviderpossessing MODULE 4 saneorsimilarstillsorknowledgeundersimilarcircumstances Know why clinical standards of care are important to follow and where to find the guidelines (AOA, AAO, COS) Standards of care hold a provider of exceptional skill or knowledge to a duty of acting as would a reasonable and prudent provider possessing the same or similar skills or knowledge under similar circumstances. neath provider'sactionsaremeasured against standardofcare o A health care provider’s actions are measured against the standard of care active in the caregiver’s profession, location, or similar community AOA evidence-based optometric clinical practice guidelines activeinthecaregiver'sprofessionlocationcommunity o OCPGs – Optometric clinical practice guidelines – Recommendations for patient care developed through a formal process that combines the best available current scientific evidence with expert clinical opinion to recommend appropriate steps in the diagnosis, management and treatment of patients with various eye and vision conditions. ocpas recommendationsforpatientdevelopedthroughaformalprocessscientific o There are currently 20 OCPGs available evidence expertclinicalopinionappropriatesteps in oxmanagement tx of AAO preferred practice pattern – PPP o eyediseases currently When patient care fits within the optometric scope of practice, optometrists 20oceansavailable also are held to the same standard of care as ophthalmologists and the American Academy of Ophthalmology’s preferred practice pattern guidelines The PPP cover 18 subspecialties and conditionsPPP optometristsheldtosomestandard care as of o covers is ophthalmologiststano'spracticeguidelines subspecialties Understand the reasons for licensure, certification of competency, continuing education and institutional accreditation (ACOE, COPE) State licensure o eachstatehasownagency inhealthdepartmentlicensestregulatesoptometricprofession manesrules tregulations Each state has its own agency within the state health department that licenses and regulates the optometric profession by formulating rules or ARBOrepresents regulations that govern and enforce the laws that grant the privilege to practice optometry as enacted by state legislatures for the public welfare. stateprovincialo The Association of Regulatory Boards of Optometry (ARBO) represents the state, provincial and territorial boards of North America. ARBO hosts the Council on Optometric Practitioner Education (COPE) which approves the continuing education (CE) courses territorialboards that optometrist need to maintain their licensure. Once licensed, optometrist register for an OE Tracker number which is used by ofNorthAmerica most state boards to track the continuing education courses you takehosts o copeapprovescecoursestracked OE Licensure is a regulatory function design to protect the public in the competent healthcare. by o licenseprotects To be licensed means that you have been granted to privilege to practice optometry in that jurisdiction by the statecboard ompetent healthcare of optometry; you must follow the rules and regulations as enacted by the state legislatures for the public welfare and safety licensed NBEO examination/certification grantedprivilegefor rowrules o NBEO independent non government non profit protects p ublicby assessing competency NBEO – Independent, non-governmental, non-profit organization whose mission is to protect the public by accurately assessing the of o ptometrist competence of practicing optometrist. Develops, administers, scores examinations, and reports the results that state regulatory boards utilize in licensing optometrists to practice. o In order to apply for an initial license in most states, along with graduating with the Doctor of Optometry degree, you must pass the NBEO examination. States vary in NBEO requisites. Some require minimum scores in specific sections. o Board certification in optometry is a voluntary process by which a practitioner can establish they exceed the basic requirements. Not currently required for continued licensureBoard certificationvoluntary Graduation from an US accredited institution accreditationsystematicrecognition educational not for currentlyrequired license o of programs Accreditation is the systematic recognition of educational institutions and programs that attain educational effective SS, integrity and y quality, entitling them the confidence of the educational community and public. Accreditation is often performed by a government. The US system is a voluntary, non-governmental evaluation which may be national, regional or professional o Accreditation Council on Optometric Education (ACOE)Aco E professional – professional evaluatorofusoptometry evaluator of US optometry schools schools Responsibilities: Review of 9 programs standards such as: facilities, faculty, curriculum, residencies, etc. at least every 5 yrs. The accreditation evaluation involves a self-study, an evaluation visit and subsequent approval, approval with recommendation or with substantial changes or denial o In order to apply for a license in most states, you must have graduated and obtained your OD degree from an accredited institution in the USA or Canada. Clinical Privileging o privileging Privileging – process process by which by whichprovider'sscope the provider’s scope of services of the servicesat facilityisdefined at the facility is defined Know the functions of state boards of optometry and national boards of examiners in optometry practicingoptometristin 900 Board of examiners in optometry … Who are they? Board o ofexaminers appointed governorodd by for voting standing noviolations Usually appointment by the governor. - Odd number for voting (5,7,9) - Practicing optometrist in good standing with no violations Some public members (1-3) - 2-year appointments, staggered for continuity staggeredfor o o 13publicmembers The board of optometry is completely autonomous and is located where the state optometry association office is. continuity y What are their responsibilities? o Protect the public safety - Establish policy in some cases – Adopt procedural rules - Provide examination and licensure o Enforcement of the rules and statutes - Report to the state regarding regulation of the optometry profession o Interact with other state boards through ARBO Regulatory board Understand the universal legal regulations of the practice of optometry Licensure, renewal, continuing education, multiple offices, mobile offices Licensure o License types: Active – If you plan to actively practice in a state, you must maintain an active status for that state license Inactive – If you opt to practice in another state, you may maintain inactive license status in the state you do not practice. You are still required to renew your license and meet all credentialing requirements as per the laws and regulations o Licensure according to levels of prescribing authority Some states further delineate the type of license based on prescriptive authority privileges whether a practitioner is allowed to use DPA> topical TPA> Oral TPA> Advanced therapeutic privileges. room o Unique licensure status up Members of armed forces in good standing with administrative boards or the department Optometric faculty certificate Public school volunteer health care practitioner program o Enforcement/reciprocity Enforcement – when the state board has authority by the state legislature to assess the equivalency of an individual applicant’s credentials to that state’s own licensure standards … Example: Faculty certificates Reciprocity – when two or more states determine their licensure standards are equivalent or nearly equivalent and enter into a ieMC PHS contractual agreement granting licenses to applicants from one another’s state. recognizing NOVA  somestatesarrowlicensurebyenforcementorreciprocity ityou haveanactivelicense standing tactivelypracticedforacertainamountoftimepriortoapplicationfor ingood licensure compliedwithall requirements Note: some states allow licensure by enforcement or reciprocity if you have an active license in good standing and actively practiced for a certain amount of time prior to the application for licensure and complied with all requirements. o The Optometry Act 4 somestatelawshavespecificguidelinesoutlinedothers Just requirestandardofcareconducttethicsforowe Definition of optometry: Some state laws specifically outline the responsibilities or scope of practice. Other states simply require that have standard of care, standard of conduct and code of ethics be followed. scopeofpracticesome states define what candoexam men partsequip can't Scope of practice: Some states define what one can do in an exam, what must be part of exam, and what minimum you equipment you DR andOD must have. Some states describe the limitations to the practice of optometry some statesdescribelimitations bothin Renewal title Title: Acceptable: Name, OD or Dr. Name, optometrist or optometric physicians or.name or or therapeutic optometrist; NEVER! Dr. Name, OD o Renewing license is not automatic, each period you are responsible for maintain it active and current. Entwaffffomatic o Fees – vary from one jurisdiction to another - Online or paper depends on the state o feesvaryonlineorpaperdependsonstate Annual or biannual due date – stiff sanctions exist for delinquent licenses. annuallbiannual stiff Depends on the state if annually, biannually, some are on your birthday or the 1st of the year.somefor sanctions delinquentcases o Criminal record – you must report any pertinent felonies, misdemeanors, insurance sanctions or malpractice onbirthday closed cases to of or ist year the bard. This I may jeopardize your license renewal cehours requiredtevidence o Continuing education – evidence of continued competency courses is required. Hours and type of CE vary per state. Patient records o maintaincompleterecordsexamtx tx to reachpt We must maintain complete optometric records about the examinations, treatments and prescriptions for each patient and we must maintain control over those records. licensedpractitioner o forit independent control overrecords A licensed practitioner shall maintain full and independent responsibility and control arrtest over all records to histx findings relating ormust bedocumented her patients and his or her optometric practice. All test performed, findings, treatments must be documented. o The licensed practitioner must legibly sign the entry for each patient encounter. o mostshall be All records shall remain confidential excepatientas otherwise provided by the law andlegibly sign recordsconfidential tkept maintained by the licensed practitioner o Statute of limitation: FL = 6 years … Child = NYC until 21 years old … Workman compensation = 30 years Howlong tokeeprecords Advertising rules FL workmancompensation so o eyrs child nyc No advertisement should be fraudulent, deceptive or misleading in any way. advertisement yrs no frauddeceptivem o Generally unacceptable to use “capping and steering” which are forms of bribery or self-referral.unacceptablecappinga steering briberyserfref o Some states dictate whether and how price or discounts may be advertised - what size font is used - who can advertise your services. o In FL: violation to advertise SUPERIOR EYE CARE, lowest prices, free eye exam with contacts, corporate optical entity advertising eye exams available some statesdictatenowpricediscountsadvertisedfontsizewhocanadvertiseviolationtoadvertisesup eye care owe i Prescriptions – spectacles, contact lens and pharmaceutical treeeyeexamwith contactscorporate optical entityadeyeexams price o Spectacle prescriptions Federal By federal law, everyone raw air mustreceivetheir spectacle pts is required to receive a copy ofcopy ofRxafter examt prescriptionpayment upon completion and payment of their exam. FL has very clear rules about what to include on a written spectacle Rx: FLhas Prescribers license number and state veryclearrulesonwhattoincludeonRx The patient name, address and birthdate Prescribed full name (with OD), practice address and phone number A Exam date a Rx, OD, OS, sphere, cylinder, Axis, add, prism amount and direction, any optional lens finishes or orders Spectacle expiration date The prescriber signature followed by OD Some states somestates arrow opticianstocopyRx from fromreadings, others do not Allow opticians to copy someone’s spectacles from glasses the lensometry iensometry Declare that a spectacle Rx cannot be “called in” but must be forwarded to the patient, optician rxcannot beincaredin or other writing Specify an expiration date and always the symbol Rx must be included specifyexpirationdatetaxsymbol Require the release of PD, and others do not specifyrequire releaseofPDother o Contact Lens Prescription don't allptsismust receivecopyof a Rxafterfinalized By federal law, everyone required to receive a copy of their contact lensfitting prescription after finalization of the fitting process In some states: somestatesarrowtofit afrom specexRx.ex Opticians are allowed to fit CL from a spectacle Inmay need these cases, the lawspt tostate isaway stipulate that the fitted tobe spectaclemay Rx must state k's require that the patient is “okay to be fit with contact lenses” or not approved for fitting with contact lenses. These states may require the keratometry readings to be released. requirestatementthatptisauthorizedformailorder after Require a statement that the patient is authorized for mail order after the final fitting is completed. finalfittingiscompleted Stipulate whether substitutions are allowed or not itsubstitutionsareallowedornot In FL, patient written authorization is required to release say a CL Rx to an outside entity The prescriber’s license number and state in FL ptwrittenauthisradtorelease The patient name, address and birth date a rx toanoutsideentity Prescriber full name (with OD), practice address and phone number Exam date Specifications: BC, Power, Diameter, type, brand, color, wear schedule, refills or supply amount to be dispensed, follow up Contact lens Rx expiration date The prescriber signature followed by O.D. o Pharmaceutical prescribing privileges scopeofpractice Since optometry is a legislated profession, touse scope pharmaceuticalsvaries statetostate of practice to utilize pharmaceutical and other treatments vary from state to state Florida legible prescription law: A written prescription for a medical drug issued by aDrug healthrxsmust belegibly care practitioner licensedprinted by lawor totyped prescribe such drug must be legibly printed or typed so as to be capable of being understood by the pharmacist filling the prescription It must contain: mustbeunderstoodbypharmacist The name of the prescriber practitioner Name and strength of the drug prescribed Quantity pf the drug prescribed in both textual and numerical formats Directions for use Dated with the month written out in textual letters Signed by the prescriber practitioner on the day when issued. Minimum equipment/exam  statesexpectoptometriststopracticestandardofcare are somestatesspecifywhattestingconstitutesminCEE o All states expect optometrist to practice to the standard of care. However, some states specify what testing constitutes a minimum or a comprehensive eye examination Patient Hx - VA (sc and cc for new patients) - External and Internal Examination - EOM, Pupils, VF Remember Minimum equipment Biomicroscopy and Tonometry - Refraction (recorded VA) - Dx and Plan y with discussing John o Some statessome assume states assume you must you have the musthave minimum equipment to practiceto minequipment topractice soc the standard totherinstrumentsforabsolutemin that must of care and other mentioned specific instruments be the absolute minimum to practice Ophthalmoscope – Retinoscopy – Keratometry/corneal topographer - Phoropter – trial lenses – slit lamp - Standard VA charts - VF Control of the optometric practice controlofoptometricpractice maynotexercise authorityor dominateinfluenceoverauthor ability toregulate o The non-licensed entity may not exercise authority or dominating influence over, have the authority or ability to regulate, direct or dominate: The type, extent, availability, or quality of optometric services typeextentavailabilityqualityofoptometricservices Information disseminated to the public regarding optometric services intogiven publicof q Fee schedules for optometric services and materials, and the establishment Time limitations on patient examinations or the volume of optometric patients thereof,toincluding optomservice billing methodsfeesof services time pt limitsonexamsor vorone A Scheduling and availability of optometric services scheduling optonservices a Files and records relating to patients and the optometricorpractice The type of ophthalmic materials available, prescribed, dispensed typeofophthalmservicesavailable nodispensed a tirestrecordsrelatingto orpractice Optometric prescriptions optom as pts Affiliation with other entities … Corporations optometrists can beanother by employed another optomphysicianormulti disciplinegroup o Generally, most states optometrist may be employed by licensed optometrist, or licensed physician (such as an ophthalmologist) or to associate with a multidisciplinary group of licensed health professionals, the primary objective of which is the diagnosis and treatment of the human body can'tbeemployed opticianorcorporation o Optometrist cannot be employed by by an optician or a lay corporation o FOA – No corporation, lay body, organization or individual other than a licensed practitioner shall engage in the practice of optometry through the means of engaging the services, upon a salary, commission or other means or inducement, of any person licensed to practice optometry in this state. licensedoptometristscanpracticeoptometry o only The law also states that “no licensed practitioner shall engage in the practice of optometry with any corporation, organization, group or lay individual” may not p ractice with Major administrative violationany incorn organizationgrouporrayindividual Florida mavorviolation in FL No optometrist shall enter into any agreement which: Limits or adversely affect the optometrist’sno shouldenter anyagreement optometrist independent professional judgement that and responsibility. nits Allows, permits or facilitates any entity which itself is not a licensed practitioner to practice optometry, oraffectsuoogement to offer optometric respon services to the public through the licensed practitioner notlicensed Controls through any means whether any aspect of the practice nopractice of optometry. The professional judgement of the licensed practitioner must be exercised solely for the benefit of his/her patients and shall be free from any compromising control, influences, obligations or loyalties Delegation of duties o Non-licensednon licensedpersonnel ox personnel cannot make dx or ortreatment treatment o Tasks must be assigned by the practitioner and must be supervised under the presence of the licensed practitioner. o The licensed practitioner is responsible and liable for all delegated acts performed by persons under his or her directtheirand general supervision o Direct supervision – supervision to an extent that the licensee remains on the premises while all procedures are being done, and gives final approval to any procedures by non-licensed supportive personnel licenseemust remainonpremiseswhileariproceduresaredone Note: as a student intern, you are working under the direct supervision of the licensed preceptor. You cannot start seeing a patient without supervision. Violations, fines, sanctions o Grounds for discipline o You must practice to the highest standard. Certain acts are considered grounds for licensure denial or disciplinary action False or fraudulent representation Practicing without a license Failure to maintain complete patients records Advertising goods or services in a manner which is fraudulent, false, deceptive, or misleading in form or content o Violations Minor administrative – does not involve patient and does not endanger the public Major administrative – does not involve patient, but does endanger the public ooestidingettisteric Minor patient care – does involve patient, but does not endanger the public Major patient care – does involve patient and does endanger the public pt notpublic Sanctions and penalties at t public o Penalties maypenalties mayresult result in a combination incombo of sanctions of sanctionsfromtime from a fine to permanent torevocation revocation of your license depending not the severity of the violation. Only major violations could result in revocation onlymavorviolationsresult in revocation o Felony or misdemeanor o 3rd degree felonies practicing Felonies of the third degree – practicing without olicense w obtaining a license, obtainbyusing one by fraud, fraud suspended license a suspended license o Misdemeanors of the second degree – saying one is licensed when they are not, knowingly employing non-licensed individuals, concealing info misdemeanorsof licensedwhennot employingnonlicensedindsconcealinto Know the legal definition of blindness and2nd levelsdegree saying of impairment in the USA definitionofblindness module legal Visual acuity /= 20/70 220170 of Mitopresentingbinocularacuity worsethanso toonotbestcorrected inbettereye miloornone I o o Moderate visual impairment < 20/70 and >/= 20/200 azono zzorzoomoderate Severe visual impairment < 20/200 and >/= 20/400 201200 2201400 severe o Blindness < 20/400 and >/= 20/1200 2201400 22011200 t Know the OSHA standards for Bloodborne Pathogens, other hazards, and the Hazard Communication standards for your practice Main occupational hazards – biological, chemical, physical, and psychological occupationalhazards biochem physicalpsychological Biochemical hazards main  causeaccidentsinvoriesstraindiscomfort factorsencountered inworkenvironmentthatmay weareresponsibletoeliminate o We are responsible to eliminate factors encountered in the work environment that may cause or potentiate accidents, injuries, strain or discomfort to our employees and our patients. Hazard communication plan o Prepare a plan for your practice including: Appointment of a coordinator within the practice for the hazard communication program Maintaining complete inventory of hazardous chemicals on-site A Maintaining material safety data sheets (MSDS) for each chemical stored on-site Proper labeling of hazardous chemicals Proper information, documentation and training of employees Proper exchange of information to outside contractors of chemical hazards Accessible copy of the standard and written program to employees Blood borne pathogen exposure plan o Prepare a plan for your practice including: Identification of employees who are at risk of exposure Identification of tasks that offer exposure Observation of “universal precautions” … Universal precautions – concept of bloodborne disease control which requires that all human blood and certain human body fluids are treated as if known to be infectious for HIV, Hep B and other bloodborne pathogens Use of PPE Proper housekeeping protocols Hepatitis B vaccination available or declination by employee Use of engineering controls and work practice controls to isolate or remove BBP hazards Regulated waste disposal Documented training and recordkeeping Accessible copy of the BP standard o Examples of bloodborne pathogens: Non- A hepatitis - Non-B hepatitis - Hepatitis B, C and delta - Syphilis - Malaria - HIV - Ebola virus o If an employee has risk of exposure, the employer must make the Hepatitis B vaccination available at no cost within 10 days of hire. o If an employee chooses to decline the vaccine, a waiver must be signed by the employee and kept on file. o The vaccine is administered by 3 vaccinations over a 6 mo. Period 20 CFR 1910.1020, employees t shall establish and maintain an accurate record for each employee with occupational exposure containing: o Employees name and ss# o Employee hepatitis B vaccination status, date administered o Results of all examinations, medical testing, post-exposure evaluation and follow up procedures o A copy of the healthcare professional’s written opinion o A copy of any specific information provided to the healthcare professional o Medical and all health-related records must be kept for the duration of employment + 30 years Know the federal laws relevant to optometric practice Sherman Act: Outlaws every contract, combination, or conspiracy in restraint of trade and any monopolization, attempted monopolization, conspiracy or combination to monopolize Federal Trade Commission Act: Bans unfair methods of competition and unfair, deceptive acts or practices Clayton Act: o Prohibits mergers and acquisitions where the effect may be substantially to lessen competition, or to tend to create a monopoly o Bans certain discriminatory prices, services, and allowances in dealing between merchants Know the FTC (Federal Trade Commission) Eyeglass and Contact Lens rules FTC ophthalmic practice rules (Eyeglasses rule): The federal trade commission monitors free trade as it pertains to ophthalmic goods FCLCA – Fairness to Contact Lens Consumer Act (TQ) o The FCLCA mandates that eye care practitioners, including optometrist, release contact lens prescriptions to their patients. o The contact lens prescription must include the following: contact Name of the patient lensrx Date of examination Issue date and expiration date of prescription Name, postal address, telephone number, fax # of prescriber Power, material or manufacturer or both Base curve and diameter In the case of a private label contact lens, name of manufacturer, trade name of private label brands and if applicable, trade name of equivalent brand name Requires contact lens sellers to verify the validity of contact lens prescriptions before releasing contact lenses to consumer s o Prescribers must respond to a request for verification from sellers o A seller may sell CL only in accordance with a CL prescription for the patient that is presented to the seller by the patient, prescriber directly, fax or verified by direct communication with the prescriber o A record of all direct communications should be kept o A seller may not alter a CL Rx Sellers seeking to verify a prescription must provide the prescriber the following: o Patient full name and address o CL power, manufacturer, BC or appropriate designation, and diameter when appropriate o Quantity of lens ordered o Date of patient request o Date and time of verification request o Name of contact person at seller’s company, including fax and phone # A prescription is considered verified only if ONE of the following occurs: o The prescriber confirms the prescription is accurate by direct communication with the seller A o The prescriber informs the seller that the prescription is inaccurate and provides accurate prescription o The prescriber fails to communicate with the seller within 8 business hours after receiving the seller request o If a provider informs the seller that the Rx is inaccurate, expired or invalid BEFORE this time, the seller shall not fill the Rx Become familiar with the federal laws such as the Sunshine Act, ERISA, COBRA, Stark II, GINA National physician payment transparency program – Sunshine Act o As part of the PCACA, CMS created rules designed to increase transparency financial relationships between health care providers and product manufacturers o The “Physician sunshine act”- requires manufacturers and group purchasing organizations (GPOs) of drugs, medical supplies, devices and biological that participate in U.S federal health care programs to report certain payments and items of value given to physicians teaching hospitals o This regulation was designed to identify potential conflict of interest between health care providers and manufacturers o The broad definition of “payment” or “transfer value” includes: Cash or cash equivalent - In-kind items or services - Provision of stock - Stock options Any other ownership interest, dividend, profit or other return on investment ERISA – Employment Retirement Income Security Act of 1974 o Sets the minimum standards for most voluntarily established pension (retirement), welfare benefit and health plans in private industry to provide protection for individuals in these plans. o Created to assure that the assets that people place in retirement funds will be there when they actually retire o Requires health plans to provide participants with important information about plan features and funding Provides fiduciary responsibilities for those who manage and control plan assets Requires plans to establish a grievance and appeals process for participants to get benefits from their plans Gives participants the right to sue for benefits and breaches of fiduciary duty COBRA – Consolidated Omnibus Budget Reconciliation Act o Gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death divorce and other life events. o Requires that group health plans sponsored by employers with 20 or more employees in the prior year offer employees and their families the opportunity for a temporary extension of health coverage (called: continuation coverage) in certain instances where coverage under the plan would otherwise end o Cobra outlines how employees and family members may elect continuation coverage … Also requires employers and plans to provide notice o Eligibility for COBRA continuation coverage won’t limit eligibility for new marketplace coverage or for tax credit under the affordable care act Stark II – Anti-self-referral, anti-kickback o The law prohibits a physician from referring a Medicare patient for certain designated health care services: to an entity with which the physician or immediate family member has a financial relationship through ownership or compensation, unless the self-referral is protected by one or more exceptions provided in the law. GINA – Genetic information nondiscrimination act of 2008 o Federal law that prohibits discrimination in health coverage and employment based on genetic information o Prohibits health insurers or health plan administrators from requesting or requiring genetic information of an individual or an individual’s family members, or using such information for decisions regarding coverage, rates or preexisting conditions. o Prohibits employers from using genetic information for hiring, firing or promoting decisions and for any decisions regarding employment Recall HIPAA and the Privacy Rule to protect health information privacy and confidentiality HIPAA – Health Insurance Portability and Accountability Act o Provides rights and protections for participants and beneficiaries in group health plans o The law includes: Protections for coverage under group health plans that limit exclusions for preexisting conditions Prohibit discrimination against employees and dependents based on their health status Allow a special opportunity to enroll in a new plan to individuals in certain circumstances. o Includes rules for privacy of patient health information (PHI) and electronic data exchange o The HIPAA privacy rule establishes national standards to protect individual’s medical records and other personal health information. o Applies to health plans, health care clearing houses and health care providers that conduct certain health care transactions electronically o Required by law to provide training for all employees under HIPPA; The law also requires you to disclose your privacy practices to your patients o The privacy, security, breech notification and enforcement rules require that providers establish policy on how PHI use must be given to patients. Know the ADA guidelines for patient accessibility in optometric offices Disability – with respect to an individual, a physical or mental impairment that substantially limits one or more of the major life activities such as: caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working Physical impairment – any physiologic disorder or condition, cosmetic disfigurement or anatomical loss affecting one or more body systems Mental impairment – any mental or psychological disorder such as mental retardation, organic brain syndrome, emotional or mental illness and specific learning disabilities ADA requirements: for the hearing impaired, visually impaired, and removing physical barriers Protect health information privacy and confidentiality Via HIPPA Recognize and prevent medical errors and malpractice The purpose of licensure us to protect the safety and welfare of the public, not to protect the optometrist Terminology Clinical practice standards of care – see above. Accreditation – see above. Board certification – see above. Licensing – see above. Credentialing – the process of establishing the qualifications of licensed professionals, organizational members or organizations, and assessing their background and legitimacy. MODULE 5 Paraphrase and interpret national health care expenditures and their impact on health status, access to care, and your practice We spend more money on health care per person 17% more than any other country Total health expenditure as a % share of GDP (gross domestic product) o USA = 8% public, 17.4% private …Canada = 8% public, 11.4 private US ranks highest in health expenditures per capita, yet the lowest in efficiency, equity and heathy lives - US healthcare ranks last among wealthy countries Hospital care achieves the highest percentage of spending; US dollars are spent mostly on health insurance Justify and Conceptualize Universal Health Care Coverage Theory and the Burden of the Uninsured What is universal health care o Universal health care is a health care system in which all residents of a geographic or political entity have their health care paid for, regardless of medical condition or financial status The intent of health care reform in the USA is to provide universal coverage for everyone while accommodating the existing private system with the attempt to not limit freedom of choice and not create a single-payer government driven system. Know the definition of health care fraud and abuse and their consequences Fraud – obtaining a benefit though intentional misrepresentation or concealment of material facts Health care fraud is: o The intentional or deliberate submission or filing of false insurance claims for the purpose of illicit gain o Lying about the patient’s condition or the types of services provided o Making claims for services or supplies never provided o Altering documents used to obtain payments o Cheating by omitting information about the condition, symptoms, or the treatment or services received o Stealing Abuse – includes excessively or improperly using government resources o Health care abuse – Similar activities to fraud, but where intent or deceit cannot be established Federal and state crime o Health care fraud is a federal crime and a crime under most state criminal codes o Fraud and abuse is discovered by internal audits, audits by insurance companies, the office of the investigator general (OIG) or individual reports Schematize the economic burden of vision conditions in the USA and consider cost control measures of health care Economic impact of vision problems 2013 - $139 billion - Money spent on eyecare in 2017 – 51.4 billion - Eye disorders 5th in direct cost The WHO is currently implementing the global action plan entitled “Toward universal eye health: a global action plan 2014-2019” o This action plan is the 1st of its kind that focuses effort on universal eye health in order to eliminate avoidable blindness by the year 2020 Elaborate on the importance of Universal Eye Health Coverage as part of Health Insurance (ReThink Eye Care) The solutions: [https://www.rethinkeyecare.com/real-solutions-now] o 1. Better access to care – More optometrist means better access for patients and their communities o 2. Mandates to affordable health care act – Force of change to make comprehensive eye health and vision care plans integrated o 3. Cost savings to plan and patient – Integrated and comprehensive eye care = patient choices and convenience, improved care and reduced costs by avoiding expensive emergency room care when circumstances do not warrant ER visits. o 4. Part of the greater health care community – due to the affordable care act, health care will soon be more interconnected among a full continuum of health care providers. Summarize and explain the health care payment mechanisms (private pay, public vs. private funded systems) Private self-pay … Doctors charges fees and patients pays them o Private pay still exists if: The patent can afford the care and chooses to pay “out of pocket” in full The patient is not eligible for insurance due to lack of employment or undocumented immigration status There are deductibles or co-payments required by the insurance that the patient must pay The patient elects a procedure or good not covered by insurance The patient chooses to go to a provider who is not contracted with his/her insurance plan Understand the government paid health care programs including Medicare, Medicaid, sCHIP, Veterans Administration, Tri-Care Medicare o Health care for retirees over the age of 65 as part of the social security system o Covers those who are permanently disabled, blind or suffer from end stage renal disease under the age of 65 o Workers pay X% of their income through the working year and at age 65 when they retire, they are eligible for part A- hospital coverage for free. Medicare parts o Part A – Hospital insurance Covers in patient care in hospitals, including critical access hospitals and skilled nursing facilities Covers hospice care and some home health care Does not cover physician visits Medical services by optometrist the patient must have Part B or Advantage plan o Part B – Medical insurance Covers doctor’s services and outpatient care Covers medical services such as physical, occupational therapy and some home health care Only covers for services and supplies when they are medically necessary Medically necessary is how we get paid Medical eye care is covered – must have a medical reason for seeking care in the cc, a medical Dx, documented in records and on the billing claim (they must match) Non-covered services: Routine eye care - Refraction (92015) - Eyewear – except: 1st pair of glasses after CAT sx. o Part C – Medicare advantage or Medicare + choice Includes: health maintenance organization, preferred provider organizations, private fee for service plans, special needs plans and Medicare medical savings account plans Medicare’s pays a fixed amount per person each month to companies offering Medicare advantage plans Medicare advantage plans offer routine vision coverage as an add-on Medicare advantage plan is a supplemental insurance and they are the ones that get the money from Medicare and manage that money for the patient, but providers must be within the plan. Only pays 80% and patient is responsible for 20% Medicare alone = you can see the patient Medicare part c + supplemental = if you aren’t part of the supplemental you can’t see the patient o Part D – Prescription drug coverage Monthly premium (elective)  Includes a gap “donut hole” between $2250 and $3600 where Medicare does not pay Becoming a provider: Apply and obtain NPI Medicare provider application (NPI, education, license, adverse legal actions) through pECOS and pay fee Medicaid o Federally supported state paid program to cover impoverished persons of all ages o “Services allowed” Inpatient and outpatient hospital - Laboratory and x-rays - Skilled nursing home services - Physicians services - Home health services Early and periodic screening, diagnosis and treatment (EPSDT) o Note: Routine eye care or wear may not be covered for adults in every state The TPA formulary is limited Referrals usually are through the PCP. sCHIP – State Children’s Health Insurance program o Federally funded and administered by CMS o Covers uninsured children under age 19 in families who earn up to $36,200/year/family of 4 for little or no cost o FL KidCare o Covers: doctor visits, immunizations, hospitalizations, and ER visits - Annual comprehensive eye exams and basic eyeglasses are covered Tricare o For family members or veterans of the military that may seek care outside the military or VA system o Covers most inpatient and outpatient care that is medically necessary and considered proven Compare and differentiate between Indemnity, Capitation, HMOs, PPOs, IPAs, ACOs, VSPs Indemnity – Fee for service health plans o Based on what is “usual and customary” - “Assignment accepted” – you get paid by the insurance o Considered to be the 1st type of traditional health insurance that people could purchase through an individual, family or group plan o Previously, you were paid the fee you charged for the service by the insurance Today, true fee-for-service plan is rare o You accept the contracted reimbursement fees and write off the difference between your set charge fee PPO – Preferred provider organization o Network of providers that agree to contractually specified reimbursement for coverage benefits with the organization offering the plan o The plan provides reimbursement for all covered benefits regardless of whether the benefits are provided with the network of providers o Instead of being bound to only use doctors in network, the patients can use doctors outside of network for an additional cost. o Payments are based on “usual and customary” in your geographical area and discipline based on a relative value scale o Do not require authorization from PCP o These plans have least co-pays but more expensive premiums HMO – Health Maintenance Organization o Pre-paid health care plan where people enroll by paying annual fee and/or premiums o Services are provided through a group of affiliated physicians and hospitals with little or no additional co-pay o Requires prior-authorizations and patients must stay with in-network providers o These plans are less expensive than PPO but are more restrictive in coverage and convenience. o Reimbursement is less o Components of HMO Strictest utilization controls - Mechanisms to monitor quality of care - Must remain in select panels of providers Payments might be based on capitation - Requires PCP – gatekeeper - Subscriber premiums usually less than other forms of coverage Minimal out-of-pocket payments by patients - Some services require prior-authorization Capitation o Set amount of money per person (per capita) covered that is paid to a health plan or doctor/practice used to cover the cost of a health plan member’s health care services for a certain length of time o Two-tiered capitation system IPA – Independent Practice Association o Group of individual physicians which group together in a practice association to better market their services to insurances o Three-tiered capitation through an IPA ACO – Accountable Care Organization o Networks of healthcare providers consisting of many stakeholders – payers, physician groups, hospitals – that receive reimbursement based on metrics of quality care, patient satisfaction and reductions in cost of care o ACO models include relationships between: Hospitals, providers and payers - Hospitals and physicians in a group practice arrangement Hospital employing physician groups - Networks of individual practices o May receive government incentives VSPs … VSP is an insurance (Vision Service Plan) that is one of the most known insurances used by optometrists Have a preliminary understanding of CPT-4 evaluation and management, ophthalmic and surgical codes CPT-4: Defines what we do (TQ) The American medical association maintains and updates the procedure codes for procedures, services, examinations, treatments and surgeries o These used to be called HCPCS Level 1 CPT-4 Category codes … Most often use category 1, level 1 CPT codes, but there also are 3 other types of CPT codes we use. Category 1 codes: o Cat 1 Level 1 codes: Exams, testing services, and surgical procedures 5-character numeric codes o Cat 1 Level 2 codes – HCPCS codes Supplies, injectable solutions, glasses, contact lenses, and screening. 5-character alphanumeric codes starting with a letter Category 2 codes: o Report quality measures for the Merit-Based incentive payment system (MIPS) o 5-character alphanumeric code ending in a letter Category 3 codes: o Emerging technologies, services, and procedures. May not be paid by insurers o Data collected used to determine whether new category 1 codes are needed.  o 5-character alphanumeric code ending with T Types of visits: o Comprehensive eye visit – must include 12 elements – New comp = 92004, established comp = 92014 o Intermediate eye visits – consist of less than 12 elements – New intermediate = 92002, established intermediate = 92012 Ophthalmic procedural codes o Refraction 92015 – always separate from exam and must be linked to ICD-10 refractive diagnostic code (each one) Evaluation and managements codes (Medical) o New patient – one who has not received any professional service from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice within the past 3 years All of the key components (history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of service o Established patient – one who has received professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years Two of the three key components (history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of service When counseling: Face-to-face time in the office is > 50% of the encounter … Non-face-to-face time (pre- and post- encounter time) is not included For most diagnostic procedures, an interpretation is required - Surgical codes start with 6 o V codes are vision related supplies including spectacles, lenses, CL Insurance guidelines specify that you must have ONE fee schedule for each CPT code, and you must charge all patients the same amount for the same service, regardless of who is paying the bill Diagnostic CPT Codes: Eye visit codes 92XXX - Medical evaluation and management codes 99XXX - Procedural codes Have a preliminary understanding of ICD-10 codes ICD-10: Defines what we find (TQ) … Used for diagnoses Allows for: o More information per code, better support for care management, quick measurements and analytics, improved ability to understand ICD-10-CM for diagnosis coding is the only part of ICD-10-CM we use Uses alphanumeric codes. Do not used ICD9 codes!! H00-H59: Disease of eye and Adnexa o Letter corresponding to the body system or condition - Avoid selecting codes with “unspecified” in front of the description More rules: o Vision insurance: refractive code must be first o Medical insurance: medical diagnosis must be first o Diabetics use code E Define insurance terminology including among others Premium: the amount you or your employer pays each month in exchange for insurance coverage Usual and customary: amount paid for a medical service in a geographic area based on what providers usually charge for the same/similar medical service Relative value units: measure of value used in the US Medicare reimbursement formula for physician services. Maximum allowable: dollar amount considered by a health insurance company to be a reasonable charge for medical services or supplies based on area Deductible: the amount of money you must pay each year to cover eligible medical expenses before your insurance policy starts paying Co-pay: one of the ways you share in your medical cost. You pay a flat fee for certain medical expenses while your insurance and the company pay the rest Exclusions: any specific situation, condition or treatment that a health insurance plan does not cover Differences between medical and vision coverage o Vision coverage: 92XXX Periodic vision exams, ophthalmic lenses, eyeglasses frames and contact lenses with allowances for coverage once every 12-24 months (Depending on the plan) Vision benefit: pays towards “routine comprehensive eye examinations” which check for but finds no medical problems Refraction is included Does not pay toward CL portion of exam, but may offer discounts … Pays/discount for eyeglasses or CL materials Does not cover any medical testing, diagnosis, consultation or treatment o Medical coverage: 99XXX Often require pre-authorization from PCP of PPO or HMO plans Medical insurance may apply toward eye care visits that are medical in nature Emergency visit = focused on a specific eye problem. Comprehensive examinations that are medical in nature DOES NOT include refraction Covers specialty testing