Healthcare Systems, Settings, and the Healthcare Team Flashcards

Which type of health insurance plan requires patients to select a primary care physician (PCP) who must provide referrals before the patient can see a specialist?

Answer: Health Maintenance Organization (HMO)

HMO plans use a 'gatekeeper' model in which the designated PCP coordinates all care and must issue a referral before the insurer will cover specialist visits. PPOs allow direct access to specialists at a higher out-of-pocket cost, and indemnity plans impose no network restrictions.

What is the primary purpose of accreditation by an organization such as The Joint Commission (TJC)?

Answer: To evaluate healthcare organizations against quality and safety standards and certify compliance

Accreditation bodies like The Joint Commission assess whether healthcare facilities meet established quality, safety, and operational standards. Accreditation is separate from licensure (a state function) and has no role in setting fees or negotiating insurance contracts.

In a medical practice, which team member is primarily responsible for diagnosing conditions and ordering treatments?

Answer: Licensed physician or advanced practice provider (APP)

Diagnosing conditions and ordering treatments falls within the clinical scope of licensed physicians and advanced practice providers (nurse practitioners, physician assistants). Administrative and billing staff have separate, non-clinical roles.

Which model of care delivery groups doctors, hospitals, and other providers together to coordinate care and share financial accountability for quality outcomes?

Answer: Accountable Care Organization (ACO)

An ACO is a network of providers who voluntarily coordinate patient care and share in savings (or losses) tied to quality metrics and cost targets, primarily under Medicare programs. This distinguishes it from PPOs and EPOs, which are insurance network structures.

A medical administrative assistant verifying that a newly hired physician's education, training, and licensure meet the required standards is performing which process?

Answer: Credentialing

Credentialing is the formal process of collecting and verifying a provider's qualifications — including degrees, training programs, board certifications, and licenses — before they are authorized to practice at a facility or be enrolled with payers. Privileging is a related but distinct step that grants specific clinical permissions after credentialing is complete.

Which of the following best describes a 'solo practice' in a medical office context?

Answer: A practice in which one physician owns and operates the office independently

A solo practice is owned and operated by a single physician who bears full financial and legal responsibility for the business. This is distinct from group practices (multiple physician-owners), hospital-based practices (hospital employs the physicians), and FQHCs (federally funded community health centers).