Healthcare Worksheet
Autor: Trina Alix • January 9, 2017 • Course Note • 732 Words (3 Pages) • 669 Views
University of Phoenix Material
Payment System Worksheet
Complete Parts A and B of this worksheet.
Part A
Complete the table by describing the term. Be clear and concise, use complete sentences, and define them in your own words.
Cite any outside resources. For additional information on how to properly cite your sources see the Reference and Citation Generator resource in the Center for Writing Excellence.
Term | Definition |
Preauthorization | prior authorization from a payer for services to be provided(Barsukiewicz, Raffel, & Raffel, 2010) |
Precertification | preauthorization for hospital admission or outpatient procedures(Barsukiewicz, Raffel, & Raffel, 2010) |
Predetermination | allows services or treatment to be reviewed for medical necessity (Brandi Orlando, 2013) |
Part B
Write a 250- to 350-word response to each of the following questions. Be clear and concise, use complete sentences, and use your own words.
- When are patient referrals needed?
”A referral is a transfer of patient care from one physician to another.” (Barsukiewicz, Raffel, & Raffel, 2010)
If it is necessary for the patient to see a specialist, other than for direct-access services or emergency care, the primary care physician must request a referral prior to the patient’s visit to the specialist. The referral must be for covered benefits under the plan. If you happen to need specialized treatment, your PCP will refer you to a specialist. I am diabetic, so my PCP refers me to a podiatrist and an optometrist. A PCP will refer a woman to a gynecologist for a PAP smear or pelvic exam. A Man may be referred to a urologist for prostate exam or anything to do with his man parts. If a patient has a heart condition, the PCP will refer them to a cardiologist. If a patient has a bone condition, the PCP will refer them to an orthopedist. If there is a back condition, they will be referred to a chiropractor. Patients with congestive heart failure, diabetes, and asthma are referred to their respective specialists. Barsukiewicz, Raffel, & Raffel, 2010 says that “in gatekeeper plans, an HMO member needs a medical referral from the PCP before seeing a specialist or a consultant and for hospital admission. Many HMOs have switched from “gatekeeper” plans that require referrals to all specialists to open-access plans, in which members can visit any specialists in the network without referrals. Even if referrals are required for specialists, patients can usually see OB/GYN specialists without referrals.” (Barsukiewicz, Raffel, & Raffel, 2010)
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