Medical Law and Ethics Ch 4

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Associate practice

A legal agreement in which physicians agree to share a facility and staff but not the profits and losses. They generally do not share responsibility for the legal actions of each other.

Capitation rate

`A fixed monthly fee paid by an HMO to health care providers for providing medical services to patients who are members of that HMO.

Certification

A voluntary credentialing process usually offered by a private professional organization, such as a school, college, or other accreditation body. It indicates that the health professional has met the standards set by a certain entity.

Conscience clause

Hospitals may choose not to perform sterilization procedures and that physicians and hospital personnel cannot be required to participate in such procedures or be discriminated against for refusing to participate.

Copayment

An agreed-upon fee paid by the insured for certain medical services.

Corporation

A type of medical practice, as established by law, managed by a board of directors.

Diagnostic related groups (DRGs)

Now used on all patients, designations which categorizes, diagnoses, and treatments into groups that are used to identify reimbursement conditions.

Exclusive provider organization (EPO)

A new managed care concept that is a combination of HMO and PPO concepts. The selection of providers is limited to a defined group and are paid on a modified fee-for-service basis. There is no insurance reimbursement if nonemergency service is provided by a non provider.

Fee splitting

When one physician offers to pay another physician for the referral of patients. Considered unethical and is a basis for professional discipline.

Fixed-payment plan

Members of this plan get complete medical care in return for a fixed monthly fee.

Franchise

A business run by an individual to whom is granted the exclusive right to market a product or service in a certain market area.

Franchisee

The person or company that holds a franchise.

Gatekeeper

The person such as a primary care physician, or entity such as an insurance company, that approves patient referrals to other physicians or services.

Group practice

Consists of three or more physicians who share the same facility and practice medicine together. A legal form of practice in which the physicians share all expenses and income, personnel, equipment, and records.

Health Care Quality Improvement Act

Passed by Congress, it provides for peer review of physicians by other physicians and other healthcare professionals. It also provides protection from lawsuits that whistleblowers may face when they report issues of potential malpractice.

Health maintenance organization (HMO)

A type of managed care plan that offers a range of health services to plan members for a predetermined fee per member by a limited group of providers which stress preventive care and patient education.

Indigent

Without money and homeless.

Licensure

Generally issued at the state level, but is a mandatory credentialing process that allows an individual to legally perform certain skills. Dictated by law there is a requirement to pass certain tests and exhibit the ability to perform certain skills.

Managed care organization (MCO)

An insurance plan that pays for and manages the medical care a patient receives.

Medicaid

A federal program implemented by the individual states that provides financial assistance to states for insuring certain categories of the poor and indigent.

Medicare

A federal program that provides healthcare coverage for three groups of people: persons age 65 and over; disabled persons who are entitled to Social Security benefits or Railroad Retirement benefits; and end-stage renal disease victims who qualify, regardless of age.

National Practitioner Data Bank (NPDB)

Assists with peer review of physicians, collects information about physicians; medical malpractice losses and settlements, investigations into licensure, and other damaging professional conduct.

Partnership

A legal agreement to share in the business operation of a medical practice; may exist between two or more physicians. Each is responsible for the actions of all the others to include; debts and legal actions unless otherwise stipulated.

Per diem

Daily rate.

Preferred provider organization (PPO)

An insurance plan in which patients use medical providers who are under contract with the insurer for an agreed fee in order to receive copayments from the insured.

Primary care physician (PCP)

They act as a gatekeeper, and is responsible for the patient's medical care and any referrals to other physicians or services.

Prospective payment system

The payment amount or reimbursement for care is known in advance.

Registration

An official record that indicates a person whose name is listed has met certain requirements in their particular profession.

Sole proprietorship

A solo practice in which a physician may employ other physicians and pay them a salary. The employer physician makes all adminstrative decisions, and pays all expenses and retains all assets.

Third-party payers

A party other than the patient who assumes responsibility for paying the patient's bills such as the insurance company.

Medical specialty board

Seek to improve the quality of medical care and treatment by encouraging physicians to further their education and training.

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