1.1 Healthcare Delivery Systems and Organizations
Key Takeaways
- Healthcare delivery systems in the U.S. include hospitals, ambulatory care centers, long-term care facilities, home health agencies, and urgent care clinics
- Managed care organizations (MCOs) include HMOs, PPOs, EPOs, and POS plans — each with different rules for referrals, networks, and cost-sharing
- The healthcare team includes physicians, nurse practitioners, physician assistants, registered nurses, medical assistants, and administrative staff
- Accreditation bodies like The Joint Commission (TJC) and NCQA set quality and safety standards for healthcare organizations
- Primary care physicians (PCPs) serve as gatekeepers in HMO plans, requiring referrals for specialist visits
- Understanding the organizational structure of a medical practice helps CMAAs route tasks, phone calls, and patient requests appropriately
Last updated: March 2026
Healthcare Delivery Systems and Organizations
Understanding the structure of the U.S. healthcare system is essential for medical administrative assistants. You will interact with various types of facilities, providers, insurance plans, and regulatory bodies on a daily basis.
Types of Healthcare Facilities
| Facility Type | Description | Examples of Services |
|---|---|---|
| Hospital (Inpatient) | Provides 24-hour care including emergency, surgical, diagnostic, and rehabilitative services | Surgery, ICU, labor and delivery, inpatient pharmacy |
| Ambulatory Care Center | Outpatient facility where patients receive same-day care and go home | Physician offices, outpatient surgery, urgent care |
| Long-Term Care (LTC) | Facilities for patients requiring extended care over weeks, months, or years | Skilled nursing facilities (SNFs), assisted living, rehabilitation centers |
| Home Health Agency | Provides medical care in the patient's home | Nursing visits, physical therapy, wound care, medication management |
| Hospice | Provides comfort and palliative care for terminally ill patients with a life expectancy of 6 months or less | Pain management, emotional support, family counseling |
| Urgent Care Center | Walk-in clinics for non-life-threatening conditions that need same-day treatment | Sprains, minor fractures, infections, lacerations |
| Federally Qualified Health Center (FQHC) | Community-based, federally funded clinics that provide care to underserved populations regardless of ability to pay | Primary care, dental, behavioral health, pharmacy |
Medical Practice Types
| Practice Type | Description |
|---|---|
| Solo Practice | Single physician operating independently; the physician is both provider and business owner |
| Group Practice | Two or more physicians practicing together, sharing overhead costs, staff, and facilities |
| Single-Specialty Group | All physicians in the group share the same specialty (e.g., all cardiologists) |
| Multi-Specialty Group | Physicians from different specialties practice under one organizational umbrella |
| Hospital-Owned Practice | The practice is owned and operated by a hospital or health system; physicians are employees |
| Concierge (Boutique) Medicine | Patients pay a retainer fee for enhanced access and services; typically limited patient panel |
Healthcare Team Members
As a CMAA, you work alongside clinical and administrative professionals. Understanding each role helps you direct inquiries and tasks appropriately:
Clinical Roles
| Role | Abbreviation | Scope |
|---|---|---|
| Physician (Doctor of Medicine) | MD | Diagnose, treat, prescribe medications, perform surgery |
| Doctor of Osteopathic Medicine | DO | Same scope as MD with additional training in osteopathic manipulative treatment |
| Nurse Practitioner | NP / APRN | Advanced practice nurse who can diagnose, treat, and prescribe in most states |
| Physician Assistant | PA | Practice medicine under physician supervision; diagnose, treat, prescribe |
| Registered Nurse | RN | Assess patients, administer medications, develop care plans, educate patients |
| Licensed Practical/Vocational Nurse | LPN / LVN | Basic nursing care under RN or physician supervision |
| Certified Clinical Medical Assistant | CCMA | Perform clinical tasks (vitals, injections, EKGs) under provider supervision |
Administrative Roles
| Role | Abbreviation | Scope |
|---|---|---|
| Certified Medical Administrative Assistant | CMAA | Front office operations: scheduling, patient intake, billing, records, communication |
| Practice Manager / Office Manager | PM / OM | Oversee daily operations, staffing, budgets, compliance |
| Medical Biller | — | Submit and follow up on insurance claims |
| Medical Coder | CPC / CCS | Assign ICD-10 and CPT codes to diagnoses and procedures |
| Health Information Technician | RHIT | Manage medical records, ensure data quality and compliance |
| Medical Transcriptionist | MT / CMT | Transcribe dictated physician notes into written medical records |
Managed Care Organizations (MCOs)
Managed care is the dominant model of health insurance delivery in the United States. Each plan type has distinct rules that affect scheduling, referrals, and billing:
| Plan Type | Network Requirement | PCP Required? | Referrals Needed? | Out-of-Network Coverage |
|---|---|---|---|---|
| HMO (Health Maintenance Organization) | Must use in-network providers | Yes (gatekeeper) | Yes, for specialists | No (except emergencies) |
| PPO (Preferred Provider Organization) | In-network preferred, out-of-network allowed | No | No | Yes, at higher cost |
| EPO (Exclusive Provider Organization) | Must use in-network providers | No | No | No (except emergencies) |
| POS (Point of Service) | In-network preferred, out-of-network allowed with referral | Yes | Yes, for out-of-network | Yes, with PCP referral |
Key MCO Concepts
- Gatekeeper model: In HMO plans, the PCP controls access to specialists. The CMAA must verify that the patient has a valid referral before scheduling specialist appointments.
- Prior authorization (preauthorization): Many plans require approval from the insurance company before certain services, tests, or procedures are performed. The CMAA often initiates this process.
- Capitation: A payment model where the provider receives a fixed per-member-per-month (PMPM) payment regardless of services rendered. Common in HMO plans.
- Fee-for-service (FFS): The traditional model where the provider bills for each service performed. Common in PPO plans.
Accreditation and Regulatory Bodies
| Organization | Abbreviation | Role |
|---|---|---|
| The Joint Commission | TJC | Accredits hospitals, ambulatory care centers, and other healthcare organizations for quality and safety |
| National Committee for Quality Assurance | NCQA | Accredits managed care plans and measures healthcare quality (HEDIS measures) |
| Centers for Medicare & Medicaid Services | CMS | Federal agency that administers Medicare, Medicaid, and CHIP; sets conditions of participation |
| Occupational Safety and Health Administration | OSHA | Federal agency that sets workplace safety standards, including bloodborne pathogen standards |
| Office of Inspector General | OIG | Investigates fraud, waste, and abuse in federal healthcare programs |
| Drug Enforcement Administration | DEA | Regulates controlled substance prescribing and dispensing |
The Joint Commission "Do Not Use" Abbreviation List
The TJC requires accredited organizations to maintain a list of abbreviations that must not be used in medical documentation due to the risk of misinterpretation:
| Do Not Use | Potential Problem | Use Instead |
|---|---|---|
| U or u (for "unit") | Mistaken for 0, 4, or cc | Write "unit" |
| IU (for "international unit") | Mistaken for IV or 10 | Write "international unit" |
| Q.D. or QD (daily) | Mistaken for Q.O.D. (every other day) | Write "daily" |
| Q.O.D. or QOD (every other day) | Mistaken for Q.D. (daily) | Write "every other day" |
| Trailing zero (X.0 mg) | Decimal point missed, 10x dose given | Write "X mg" (no trailing zero) |
| Lack of leading zero (.X mg) | Decimal point missed, 10x dose given | Write "0.X mg" (use leading zero) |
| MS, MSO4, MgSO4 | MS confused for morphine sulfate or magnesium sulfate | Write "morphine sulfate" or "magnesium sulfate" |
Test Your Knowledge
In which type of managed care plan does the primary care physician (PCP) serve as a gatekeeper, requiring referrals before a patient can see a specialist?
A
B
C
D
Test Your Knowledge
According to The Joint Commission "Do Not Use" abbreviation list, which abbreviation is prohibited due to the risk of being misread as "0" or "4"?
A
B
C
D
Test Your Knowledge
A patient with a POS (Point of Service) plan wants to see an out-of-network dermatologist. What must the patient do?
A
B
C
D