CERTIFIED MEDICAL

ADMINISTRATIVE

ASSISTANT

ADMINISTRATIVE Means you organize and process. You are the key member in the front

office operations. You are responsible for ensuring the

fast-paced workplace runs smoothly.

ACUTE CARE 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.

NON-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 non-acute services.

SHORT-TERM VS. LONG-TERMCARE 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 VS. NON-EMERGENT CARE 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.

WALK-IN CLINIC 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.

URGENT CARE CENTERS 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.

PROVIDERS OFFICE 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.

HOSPITALS Provide Acute, Non-acute, Emergent,

Non-emergent 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.

HOSPITALS 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.

LONG-TERM FACILITIES Skilled nursing facilities or assisted

living facilities (formerly known as nursing homes)

Staff includes: RNs, LPNs, Nursing assistants.

EMERGENCY MEDICAL SERVICES (EMS) 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.

LABORATORIES 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

PHARMACIES Generally community-based pharmacies

serve the community and hospital based serve hospital patients.

Some hospitals do have public pharmacies.

ADMINISTRATIVE AND FINANCIAL ORGANIZATIONS 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

PHYSICIANS 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

PHYSICIAN SPECIALTIES 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)

NURSES 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.

PHYSICIAN ASSISTANT Examines patients, diagnoses,

prescribes treatments and medications, and performs treatments and procedures. Must perform under the direct supervision of a Physician.

WORK ENVIRONMENT 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.

BEFORE THE PATIENTS ARRIVE 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.

WHEN PATIENTS ARRIVE 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.

UNEXPECTED DISRUPTIONS Medical emergencies Staff absence Poor staffing Late or no-show patients Patients who end up requiring more time

Be adaptable and imaginative. Document no-shows, follow up with patient. If a true emergency refer them to the ER

POLICIES AND PROCEDURES 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.

ESCORTING THE PATIENT TO A ROOM Confirm identity Confirm by asking information instead of

telling them. They may agree and have not heard you correctly.

CHECKING OUT 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)

SCHEDULING 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 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.

DOCUMENTS 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)

HEALTH INSURANCE FORMS 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.

OTHER FORMS 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.

OTHER FORMS 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)

OTHER MEDICAL FORMS 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.

MANAGING INCOMING/OUTGOING CORRESPONDENCE 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.

PREPARING SPECIMENS FOR DELIVERY TO THE LABORATORY 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.

PROCEDURES AND TESTS 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

INPATIENT ADMISSION 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.

CONFIRMATION 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.

CORRESPONDENCE 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.

CORRESPONDENCE Much of the correspondence that comes from

a clinic or physician’s office is formal, business-type 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.

MANAGING PATIENT MEDICAL RECORDS 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.

RESPONSIBILITIES OF A MOAA 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)

WORKING WITH OTHER DOC’S, FORMS, FILES, AND RECORDS 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)

CONFIDENTIAL FORMS 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.

PROFESSIONAL CONDUCT 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.

FINANCIAL PROCEDURES 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 VS. MEDICAID Medicare: provides health insurance to

older adults, retired individuals.

Medicaid: provides health insurance for the indigent and to some people who have disabilities.

HEALTH MAINTENANCE ORGANIZATIONS (HMOs) 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.

ASPECTS OF HEALTH INSURANCE 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.

COPAYMENTS 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.

DEDUCTIBLE A deductible is the amount of money

the patient has to pay for services before the health insurance company pays.

EXCLUSIONS 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.

PRECERTIFICATION 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.

LIMITS 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.

PROVIDER NETWORK 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.

REFERRALS 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)

FINANCIAL AND HEALTHINSURANCE PAPERWORK 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.

SUBMITTING CLAIMS 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/CMS-Forms/downloads/CMS1500805.pdf

ICD / CPT 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 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 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 AND BOOKKEEPING 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.

ACCOUNT 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.

ACCOUNTSPAYABLE/ RECEIVABLE 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.

DEFINITIONS 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.

DEFINITIONS 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.

DEFINITIONS 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.

BOOKKEEPING (8 STEPS) 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 MANAGEMENT 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.

DEFINITIONS 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

DEFINITIONS 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.