Transcript Non-acute care - Effingham County Schools

 Means
you organize and process.
 You are the key member in the front office
operations.
 You are responsible for ensuring the fastpaced workplace runs smoothly.
 For
patients who need immediate assistance
for recently-developed diagnoses.
 Ex.
Someone who suddenly develops severe
abdominal pain and vomiting is having an
acute problem and needs acute care.
 For
patients who have chronic, persistent or
long-lasting, diagnoses.
 Ex.
Someone who has Alzheimer’s disease for
many years and is relatively stable has a
chronic medical condition and can use nonacute services.
 Short-term:
For patients who have diagnoses
that health care workers can quickly resolve.
 Long-term:
For patients who have diagnoses
that will take a little longer to resolve.
 Emergent:
For patients who need immediate
assistance.
 Ex. A patient who suddenly develops severe
chest pain needs to see a physician right
away.
 Non-emergent: For patients who do not.
 Ex. Someone who has mild signs and
symptoms of the flu for a day or so, but is
still able to function, can wait a bit to see a
physician.
 Generally
offer non-acute, non-emergent,
short-term care and services.
 May be staffed with any of the following:
Physician, physicians assistant, nurse
practitioner, nurse, and medical assistants.
 Typically do not treat complex problems, and
they cannot provide monitoring for any
significant period of time.
 Some clinics have a stable patient
population, but many people use clinic on an
as-needed basis.
 Alternative to an ER in some cases.
 Retail
Walk-in clinics.
 A higher level of care.
 Can only treat non-life threatening
diagnoses.
 If the case is more serious the center will
stabilize patient and arrange for transport to
the Hospital Emergency room.
 Staff includes: Physicians, PA’s, nurses,
nursing assistants, medical administrative
assistants, office personnel, medical
assistants and phlebotomy technicians.
 Typically
have a stable patient population.
 Little to no walk-in accommodations.
 Some provide medical exams, basic
laboratory work, and provider evaluations,
while others perform treatments and
procedures.
 Staff includes: Physicians, Nurses, NP’s, PA’s,
Medical administrative assistants, office
personnel, Medical Assistants, Phlebotomy
techs.
 Provide
Acute, Non-acute, Emergent, Nonemergent care.
 Some also provide Long-term care.
 Hospitals can monitor patients for more than
a short period of time (Admissions)
 Capabilities depend on equipment, facilities,
staff, and medical specialties.
 Admitting
privileges: a provider who has a
formal agreement with the hospital and can
admit patients to that hospital.
 Attending physicians: The provider that has
admitting privileges. These physicians are
responsible for day-to-day care of
hospitalized patients.
 Staff includes: Physicians, (some interns at
teaching hospitals) NP’s, PA’s, RN’s, LPN’s,
CNA’s, and various technicians.
 Skilled
nursing facilities or assisted living
facilities (formerly known as nursing homes)
 Staff
includes: RNs, LPNs, Nursing assistants.
 Respond
to community medical emergencies
and treat and transport injured or sick
individuals to the appropriate health care
service.
 EMS Staff: 911 operators, EMT’s, paramedics.
In some areas nurses participate too.
 Poison control can also be part of the EMS
system.
 Can
be part of a hospital or clinic, or be
independent.
 Obtain samples of blood, feces, urine, and
other body fluids.
 Staff include: medical technologist and
technicians, phlebotomists, specimen
processors, physicians known as pathologists
 Generally
community-based pharmacies
serve the community and hospital based
serve hospital patients.
 Some hospitals do have public pharmacies.
 Do
not provide patient care
 They manage the delivery of care, develop
guidelines for standards of care, monitor and
safeguard public health, and play a role in
the financial aspects of health care.
 Some are responsible for licensing and
disciplining health care professionals.
 Ex. Public Health dept., State boards of
medicine or nursing, health insurance co.,
CDC, FDA
 Doctors:
diagnose illnesses and injuries,
prescribe treatments, and perform
procedures.
 They are legally and professionally
responsible for determining why a patient is
suffering and how to treat the condition.
 Other professionals who diagnose and treat
do so under the supervision of a physician
 Physicians
can specialize in an area of health
and medicine, a specific disease, or a
specific organ system.
 Ex. Cardiologist, Surgeon, Pediatrician
 Physicians spend 4 years in medical school,
pass a licensing exam and are legally allowed
to diagnose and prescribe.
 Physicians then spend years in training
(internship/residency)
 Nurse
Practitioner: advanced practice
registered nurses, with a master’s degree or
doctorate and a specialized are of practice.
 They can prescribe and treat as well as
independently bill insurance companies.
 Nurse: Provides direct care to patients.
 Nursing Assistant: (Patient care assistants)
direct patient care, rarely administer meds.
 Examines
patients, diagnoses, prescribes
treatments and medications, and performs
treatments and procedures. Must perform
under the direct supervision of a Physician.
 Fast-paced
with long hours. Sometimes
reporting to multiple physicians and working
weekends
 Stressful because of the high level of
accuracy and competency required.
 Highly interactive with patients, physicians,
health insurance companies, pharmacists all
while under pressure.
 Check
the environment (no safety issues).
 Make sure the reception area is clean and
well-organized.
 Confirm the patient reception area is clean
as well as examination rooms.
 Review the schedule.
 Gather patient charts and review them.
 Have Emergency contacts readily available.
 Look for missing or incomplete paperwork.
 Open Electronic Medical Records program if
used.
 Greet
the patients with eye contact and a
pleasant tone of voice.
 Utilize sign in sheet if necessary.
 Look for signs of discomfort or visible
sickness.
 Use good judgment if a patient appears to be
in distress and have a nurse or physician see
the patient immediately.
 Medical
emergencies
 Staff absence
 Poor staffing
 Late or no-show patients
 Patients who end up requiring more time
 Be
adaptable and imaginative. Document noshows, follow up with patient. If a true
emergency refer them to the ER
 Make
patient aware of privacy issues,
financial obligations, and how to make,
cancel and confirm appointments.
 Paperwork: Insurance information, consent
for treatment, Release of information (ROI),
Referral forms, medications, basic
information
 Be aware that sometimes patients show up
on the wrong day/time. Always confirm their
appointment when they sign in.
 Confirm
identity
 Confirm by asking information instead of
telling them. They may agree and have not
heard you correctly.
 Collect
copayments or coinsurance
 Give any referral paperwork
 Give any written prescription
 Schedule a follow-up visit if necessary
 Ask if there are any additional questions they
may have before they leave.(refer to a nurse
if they have a clinical question)
 If
there is a disruption during the day make
sure patients are aware of their wait time.
 May need to call afternoon patients to
reschedule.
 Confirm appointments prior to the day.
 Base scheduling on patient need.
 Check to see if they were referred.
 Obtain patient information.
 See if there is a physician preference.
 Give preparation instructions.
Written orders are necessary for patient care to
proceed smoothly and to minimize the error
rate. These orders are documentations of the
treatment plan that the physician has for the
patient. Hospitals need written orders to admit a
patient, and once a patient is in the hospital,
written orders dictate any tests, treatments, or
medications the patient needs.
 Verbal orders are usually given in emergency
situations.
 Pas, NPs can write orders for tests, medications,
and treatments, but those are the only health
care professional that can do so.

 Pharmacy:
Drug enforcement administration
(DEA) identifies the physicians who can
legally prescribe narcotics. (oxycontin,
oxycodone, hydrocodone, fentanyl, lorcet,
vicoden, codeine)
 Non-narcotic drugs prescriptions are written
on a pad and are also known as a “script”
 Referrals: Similar to a prescription, is for
other services.
 Protected Health information (PHI)
 Claims
form is a standardized form that a
provider’s office submits to a health
insurance company.
 It is a request for payment for the services
the provider has given to the patient.
 The Centers for Medicare and Medicaid
Services (CMS) designed and approved a
standard, commonly-used form called the
CMS-1500 claim form.
 Health
insurance referrals: some insurance
companies require a referral to see a
specialist.
 Patient Health History: Quick reference sheet
for the provider to see the patients medical
history.
 Informed Consent: Identifies the patient,
procedure or operation that he will receive,
as well as the physician that will be
performing the procedure or operation. Lists
and explains the potential risks of the
procedure or operation.
 ROI
(release of information)
 HIPAA: confidentiality forms
 Order Forms: for diagnostic procedures. May
be paper or electronic.
 Advance Directives: (living wills) a set of
instructions that outline what type of care a
patient wants, and what type of care she
does not want, in the event she can no
longer make these decisions. (do they want
cpr)
 Nurses
notes
 Vital sign charts
 Medication records
 Assessment sheets
 Discharge order sheets
 Triage sheets
 Office specific forms: Ex. Dermatology uses
forms illustrating the human body to
document the location of skin lesions.
 You
must learn to prioritize by urgency.
 Document all calls both incoming and
outgoing.
 Outgoing: Physician referrals…you may be
responsible for scheduling the patients
appointment with a specialist.
 Referrals can also be sent with the patient or
faxed to the office.
 Follow-up must be done to ensure contact
was made.
 Must
clearly label with patient’s name,
medical record number or SSN, the date and
time obtained.
 Typically done by a phlebotomist, lab tech,
nurse, but occasionally a medical
administrative assistant.
 A requisition should go with the specimen
including all information noted above,
insurance information, name of the test, and
the physician who ordered the test. Also
contact information for the office.
 Simple
blood work or a routine chest x-ray
typically do not need an appointment. A
faxed order will be enough for the patient to
arrive at their convenience.
 Other tests and procedures will require an
appointment.
 Ex. Ultrasounds and MRIs
 Requires
an order from a physician
 Phone # for the hospital
 Copy of patient’s chart/medical record
 Phone # for patients insurance company
 Call
the hospital admissions dept and they
will give you instructions for the when and
where the patient is to arrive.
 Part
of your professional communication
involves CONFIRMATION.
 Need to confirm that faxes are sent to the
correct place. (follow-up with a phone call)
 Never
alter a form. If you make a mistake
when you are filling out a hard copy
document, or form, do not attempt to erase
or use correction fluid. Instead, start over.
You may be asked to :
 Transcribe, whether from dictations or drafts,
medical histories, physician’s orders, or medical
records.
 Writing or editing other types of
correspondence, such as memos, letters, report
forms, invoices, and financial statements.
 Editing and/or proofreading incoming and
outgoing correspondences.
 Signing for packages, opening mail, sorting and
processing mail, as well as routing mail to the
appropriate staff member.


Much of the correspondence that comes from a
clinic or physician’s office is formal, businesstype correspondence. Creativity is not necessary,
but being concise is. When you are writing or
editing documents, make sure there are no
spelling or typographical errors and that the
content of the correspondence is accurate. The
correspondence should have the name, address,
telephone # of the clinic or office. The tone and
content should be professional, and the
correspondence should contain only the
necessary information to transmit the message.
Patient chart documents:
 Patient care: what care the patient receives and
why, who delivers the care and when, and how
the patient responded
 Medical history: past and current medical
problems, including surgical procedures
 Medication list: all of the medications a patient
is currently taking, as well as medications he has
previously taken
 Test results: from blood tests, EKGs, and x-rays
 Notes: any professional who cares for the patient
must document their care.

 Secure
the chart.
 Ensure privacy. Only release information with
the patient’s consent.
 Electronic medical records are secured by
password protection given to only certain
staff.
 Only transmit information to someone who
has a legitimate interest in the patient’s
care. Known as Treatment, Payment, and
Operations (TPO)
 Reports
for insurance companies
 Claims forms, Medicare audits
 Professional continuing education records
 State professional licensure doc’s
 Tax documentation
 Financial transactions
 Inventory
 Business contacts (utilities, computer
services, phone services)
 Track
all confidential information that you
email, fax, mail.
 If a physician directs you, you may have to
respond to subpoenas for medical records.
 Subpoenas is a legally binding request for
records or documentation.
 Make sure you notify and obtain approval
from the physician for the release of the
record or documents.
 Send a copy, not the original.
 Be
Punctual, dependable
 Be Honest
 Provide updates to patients
 Be accurate
 Have empathy
You may also be required to arrange continuing
education classes, seminars, conferences for
the staff.
 Premiums:
Health insurance companies,
often referred to as a third-party payers,
agree to pay for a patient’s health care
costs, such as medications, hospital stays,
and physician fees, in exchange for monthly
or yearly payments called premiums.
 In
some cases, workers comp, or auto
insurance may pay for care.
 Medicare:
provides health insurance to older
adults, retired individuals.
 Medicaid:
provides health insurance for the
indigent and to some people who have
disabilities.
 Managed
care organizations that are typically
more structured and organized than
traditional health insurance companies.
 These take an active role in encouraging and
rewarding healthy behavior and preventative
care.
 Take an active role in overseeing the
distribution and use of health care services.
Practices who agree to treat patients with a
HMO must agree to the guidelines and
restrictions of the HMO.
 Contracts
 Insurance
companies/health care
professionals/ patients enter into contracts
with one another.
 Insurance co. agree to pay in exchange for
premiums from the patient.
 Medical professionals agree to accept a
certain amount of reimbursement from the
health insurance co.
 Financial implications for breaches in the
contracts.
 The
majority of health care services require
the patient to pay for part of the cost at the
time she receives the service. This is a copay.
 Most copayments are a small percentage,
however, some require large amounts.
A
deductible is the amount of money the
patient has to pay for services before the
health insurance company pays.
 Exclusions
are the types of health care
services that health insurance companies do
not pay for.
 Typical for services that are not Medically
necessary.
 Ex. Plastic surgery, cosmetic surgery, or
experimental services.
 Health
insurance companies want
notification before a hospital admits a
patient, before providers perform and
operation, and before other procedures or
treatments begin.
 Calling the insurance company for prior
approval is Precertification/
preauthorization.
 Each company has different rules.
 Every
health insurance company has limits.
 A limit is the total amount that a health
insurance company will pay for procedures
and services.
 Ex. Health insurance will only cover a certain
amount of physical therapy visits in one year.
 The
physicians, hospitals, and other
providers that have contracts with a health
insurance company.
 In
some cases, the insurance company will
not pay expenses incurred at an out of
network facility.
 Especially
with an HMO, referrals are
necessary.
 Some insurance will not cover a visit that
was not directly referred from the PCP.
 Patient
may have to pay (Out of pocket)
 New
patients need to complete financial and
insurance forms.
 All information must be confirmed for
accuracy.
 The patient Guarantor is the person who
agrees to pay for services (usually the
employee)
 Always ask if insurance has changed.
 Medicare patients receiving services that are
not covered will need to sign an ABN,
advanced beneficiary notice acknowledging
that Medicare may not pay.
A
claim is the bill sent to the insurance
company from the health care provider.
 Universal claim form is CMS-1500
 CMS-1500 consists of 2 parts and 33 separate
areas to be completed.
 http://www.cms.gov/Medicare/CMS-
Forms/CMSForms/downloads/CMS1500805.pdf
 International
classification of diseases code
(ICD) for diagnoses
 Current
procedural technology code (CPT)
for the treatment provided.
 Follow-up
with claims. Some insurance
companies process their own claims, others
use a third-party administrator (TPA)
 Billing:
securing and processing money owed
by patients
 MOAA job to create and mail statements and
bills for money that patients owe.
 Consider bills a documentation of an
obligation to pay.
 Bills are often Itemized, meaning there is a
line-by-line list of all of the services,
supplies, and medications the patient
needed.
 Fees
are the amount of money the health
care facility or medical professional charges
for services it delivers.
 Fees must be reasonable and customary, and
not be substantially different from the fees
that other hospitals and providers charge.
 Typically the health insurance companies
determine the fees.
 Accounting:
records, classifies, and
summarizes financial transactions.
 Bookkeeping:
entails keeping track of
earnings and spending, and maintaining a
record of what others owe and what your
office has collected.
 An
account is the financial record for a
patient, business, or organization. A patient
account documents what services the office
has provided to the patient, the charges for
those services, the paid amounts, and the
owed amounts.
 An account can also be a record of a clinic’s
or an office’s financial transactions with a
supplier or medical equipment and
medications. This type of account outlines
the financial obligations and history the
clinic or office has with the supplier.
 Accounts
Payable: refers to unmet financial
obligations, meaning unpaid bills that a
clinic, physician’s office, or hospital owes.
 Accounts
Receivable: The amount that
patients or health insurance companies owe
to a clinic, physician’s office, or hospital.
 Invoice:
a bill to a supplier or business
 Income: anything earned
 Income statement: Profit & Loss statement.
Shows financial performance of a business or
organization over a specific time period.
 Expenses: Money that a business or org.
spends for the purpose of operating. Ex.
Supplies, salaries, insurance, meds, equip.
 Receipt: a document of payment for goods
and services.
 Deposit
slip: a record of money or funds paid
into an account.
 Credit balance: Shows that a patient,
business, or organization paid more than it
owed and therefore has a credit in the
account.
 Credit: a payment. Ex. You credit the money
a patient pays to her individual account.
 Debit: a charge or something that someone
owes.
 Balance:
the difference between debit and
credit. It can be positive or negative.
 Cash flow statement: A record of how much
money is being spent and on what the money
is being spent.
 Balance Sheet: a statement that reflects the
financial health of a business or org. at any
point in time.
 Review
the transactions for the specific time
period you are using.
 Enter transactions in the appropriate place.
 Post to the right account
 Check the trial balance (a snapshot of the
financial status)
 Make adjustments for any errors
 Enter adjustments to accounts
 Prepare income statement
 Once balance sheet is correct they cycle is
complete.
 Risk
is a situation or condition that can result
in injury to a patient or harm to an
organization.
 Risk Management: the interventions and
strategies that control risk.
 2 parts: assessment-identify, assess, and then
assign each risk a priority.
Management- use resources to manage and
reduce the indentified risks.
An ongoing process where the risks and
working environment are constantly
changing.
 Compliance:
following standards, rules, and
regulations.
 Compliance officer: the person in the
workplace who is responsible for the
provider’s compliance with all HIPAA
regulations.
 Medical Error: Harm caused to the patient
that results from the failure of a planned
action to be completed as intended or the
use of a wrong plan to achieve an aim
 Criminal
Law: law that is involved with crime
against the state
 Reasonable standard of care: A level of care
tat is safe, prudent, and within the norms of
the medical community.
 Abandonment: discontinuing medical care to
a patient without proper notification.
 Civil Law: law that is concerned with
obligations, responsibilities, and disputes
between individuals and organizations.