A primary care physician (PCP), utilization review, case management, the local authority responsible for determining when and what services a patient can access and receive reimbursement. The gatekeeper PCP is involved in overseeing and coordinating all aspects of a patient's medical care and making referrals to a specialist A federal plan for those 65 and over and disabled that are eligible for social security benefits regardless of financial and for individuals and their dependents who require kidney transplantation or dialysis. A state and a federal government program that provides health coverage for people with low incomes and limited resources. Each state has its standards for qualification, but most health care costs are covered for
& Torrens, page 205). As for as the hospital, Medicare and private insurance are the primary
Healthcare providers must make their treatment decisions based on many determining factors, one of which is insurance reimbursement. Providers always consider whether or not the organization will be paid by the patients and/or insurance companies when providing care. Another important factor which affects the healthcare provider’s ability to provide the appropriate care is whether or not the patient has been truthful, if they have had access to health, and are willing to take the necessary steps to maintain their health.
The private insurers are patients with other insurances. Under Medicare and Medicaid, services that are provided by the hospitals are paid by a prospective reimbursement. Prospective reimbursement is established before the services are provided. They have a defined dollar amount per day and per diagnosis. They also use a fee scheduled by CPT code or procedure code which is usually used for physicians. Since these types of insured patients only are billed a certain amount, most procedures are not fully reimbursed. Retrospective reimbursement is determined after the services have been delivered. This is one of the reasons organizations are struggling. Along with less reimbursement, the CPT codes or procedure codes have to be correct according to the procedure ordered. “If an organization wants to get paid, its better off taking the time to make sure all its codes are accurate, timely , and meet all payers’ requirements ”(Kapsambelis, 2004, p. 3).
Another downfall to HMO coverage is selective-contracting. This is a process where hospitals deny treatment to patients because their...
Three areas that define the provisions of comprehensive health care services and are commonly used for utilization monitoring and control are gatekeeping, case management, and utilization review (UR). Gatekeeping is used by HMOs where each member designates a primary care provider (PCP) that is responsible for coordinating all care services needed for the enrollee in a managed care plan. Case management involves an experienced health care professional with knowledge of available health care resources. `Case management services are designed to identify spec...
In consequence, this will limit poor adults finding the proper treatment since many doctors do not accept Medicaid patients. High rates of uninsured populations were associated with lower primary care capacity (Ku et al., 2011). Thus, expanding insurance coverage can support more primary care practices in rural areas and can help equal the gap in primary care positions. The impact of not expanding affects APRN practice by limiting them to practice in areas where they are needed the most. This not only affects APRNs from practicing without a physician supervision but also limit those that need coverage for basic preventive measures to reduce non-paying visits to the emergency room. Ensuring access to care will be contingent upon the ability to attain progress from insurance coverage and primary
A mandate will be made through this health care reform plan that will make providers more involved in the care of their patients. Steps will be taken to help increase the number of physicians in areas experiencing shortages along with incentives for physicians to become family practitioners. Preventative care will be the focus therefore annual checkups and routine procedures will be covered by all insurances. A coordination track where doctors, nurses, and other providers work effectively and efficiently in teams, analyzing the outcomes and processes of care to rid the system of waste will be created (Cortese & Korsmo, 2009).
...cern is the need to revise state laws governing NPs. Drafting correct legislation to clarify a NPs scope of practice is absolutely necessary to increase primary care capacity. “In some states, NPs provide care without any involvement from a physician. In other states providing the same care requires that NPs collaborate or even be supervised by a physician”. These are fundamental services that states are restricting NPs from. In addition, twenty-seven states have no restrictions on diagnosing and treating, where twenty states only require writing documentation. The remaining states have requirements but, no written documentation is necessary. It is clear that certain states have taken the correct steps to create a favorable situation for NPs. While these states have taken great steps in helping expand PCPs, other states need to follow suit. Law follows practice.
Kelly, Mark; Koula, Donald; Westfall, Laura, (August 2010). Compensation and Benefits Insight. Interim Final Regulations Under PAACA: Pre-existing Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections. Retrieved on Feb. 1, 2011 from http://www.kslaw.com/library/publication/HH082310_Westfall.pdf
Previously Prior to 2014, the law established a pre-existing conditions insurance plan (PCIP) with the purpose of funding new high-risk pools in each state, ...
The contentious debate about our healthcare system is an epitome of the ongoing political circus in America. With the 2012 elections looming just around the corner, we can expect the vitriol to rise rapidly. Our country spends twice as much on health care per capita compared to other developed countries. The current system is so dysfunctional and projected spending will increase every year, putting an unbelievable strain to our fragile economy. Majority of health care dollars spending are channeled on to patients with chronic illnesses, many of which can be prevented. Unfortunately, medical doctors practicing preventive care are being squeezed out of the equation. The shortage of primary care doctors in America is inevitable because of limited income, lesser prestige, and fewer opportunities.
Medicare is the nation’s largest health insurance program. Generally, you are eligible for Medicare if you or your spouse worked for at least ten years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States. Medicare-covered services include hospital insurance, inpatient hospital care, skilled nursing facility care, home health care, hospice care, and medical insurance (Medicare U.S.) With such an encompassing effect on the health insurance field, Medicare provides a haven for older individuals, and end-stage renal disease (ESRD) patients who require the best medical care for whatever possible reason. The only problem with this scenario is that doctors are turning many older patients away because they have Medicare. Why do doctors turn away Medicare patients? Is there a reason why certain doctors turn away certain patients?
The federal and state governments are trying to find a way to managed their Medicaid by reducing costs and improving the amount of quality the Medicaid provides. Both federal and state governments are trying to eliminate unnecessary services and rely more on their primary care and the coordination of care. sta...
Approximately 1 in 5 Americans do not have medical insurance and are more likely to lack a usual source of medical care, and more likely to skip routine medical care because of the very high costs, increasing their risk for serious health conditions. For the program, increasing the access to routine medical care and medical insurance are very important steps to achieve their goal of improving America’s health. The access to health services leading health indicators are those with medical insurance and a usual primary care provider. The access to health services in a regular basis can prevent disease and disability, detect and treat health conditions, increase quality of life, decrease the probability of premature death, and increase life
The way Medicare was originally organized, the concerns of physicians and their prerogatives were kept largely in mind. The federal government allowed physicians to remain autonomous in terms of how they ran their organization, and no state doctors were hired to provide competition. The purpose of Medicare was simply to offer a greater base of people the ability to benefit from health care and proper treatments for their conditions, thus offering physicians no competition from a rigid state system. Doctors could practice as they always did, but merely had a higher base of patients they could work on, their operations and procedures being paid for through government subsidies and Medicare. Medicare imposed much more change on an administrative level than a direct influence on the doctor’s practice, making their work relatively unchanged. Physicians were able to see as many elderly patients as they wanted without the fear of impoverishing them, and making sure that they themselves were also paid (Stevens 1998, p. 451).