As a resolution analyst at UnitedHealthcare (UHC), over ninety percent of my decisions are based on evidence provided by providers’ and members’ health policy contract and UHC reimbursement policies. The health policy contract provides payment regulations on how to correctly make a decision of either a claim is to be denied, paid or if additional steps are required. In a case where a member is asserting that an out-of-network provider should be reimbursed in-network based on their research involves investigating beyond the member’s contract and UHC reimbursement policies to justify an overturn. If the member provides proofs such as a copy of the participating provider listing on UHC's website or the provider proper Tax ID to support their…
Cassie Thorne of Mackinaw Administrators Insurance Company referred this file for medical case management. Instructions were given to meet with Timothy Blackmore and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery.…
1: Complete a one page position paper (your opinion) about current health and human services reimbursement.…
One of the biggest hesitations would have to be cost to build an implement such a system. The technique depends on an organization having "clean" data to analyze, which requires data being scrubbed and moved to data warehouses. Many payers lack the money and manpower to build and maintain these warehouses. (Kongstvedt, P., Capagemini). In addition, internal politics and the numerous constituencies within a managed care organization can make it difficult to focus data mining efforts, says Scott Kozicki.…
Western Region Community Health Centre has collaborated with Doutta Galla Community Health and North Yarra Community health; now the three groups operate under the umbrella of Cohealth. In turn Cohealth has become one of the largest community health organisations in Australia. Cohealth provides a comprehensive range of services in mental health, oral health, alcohol and drugs, medical, aged care and family violence (Cohealth 2016).…
There are many factors fused together that affect the health of communities and individuals. Whether individuals are healthy or not, is determined by their environment and circumstances. These factors include where we live, the condition of our genetics, environment, our education and income level, and our relationships with family and friends all have considerable impacts on health, considered that the more widely known factors such as availability and use of health care services often have less of an influence( World Health Organization (2010).…
From these chapter I have gain the knowledge of know, the delivery of health traditionally evolved around the individual relationship between the provider and patient/consumer. The payment was either provided by a health insurance company or paid out of pocket by the consumer. This fee-for-service system or indemnity plan increased the cost of healthcare because there were no controls on how much to charge for the providers service. As healthcare costs continued to spiral out of control throughout the decades, more experiments with contract practice and prepaid service occurred randomly across the U.S. healthcare system (Shi & Singh, 2008)…
This assignment is to discuss the major provisions of the Massachusetts health care reform laws of 2006. In April there were about fifty eight which were put in to the law. By putting these into effect they made a stand for the health care reform. It was then that Massachusetts could provide affordable health insurance for its residents. When the legislation met they came to a compromise in which it was reached by the then Governor Mitt Romney who was a republican, and was also joined by Robert Travaglini and Salvatore Dimasi. It was discussed and believed that everyone in the state should have health insurance, but they were in hopes that it would be affordable. They finally decided to make insurance affordable as long as they could use…
The individual mandate in health reform is quite controversial. Discuss one policy argument supporting the mandate and one policy argument opposing the mandate=============.…
For the past several years, the health care and insurance industries in America have been undergoing significant reform in order to rein in the high cost of delivering health care services. Managed care has become a cornerstone of this process (Strickland, 1995). The case management industry (with its focus on cost containment, managed competition, and quality care) is playing an increasingly important role in the managed care environment (Owens, 1996). According to Mullahy (1995a), the number of case managers has risen astronomically in recent years. These individuals come from diverse professional backgrounds and practice settings that include nursing, rehabilitation counseling, and social work.…
Health care is always going to be an important issue, especially when much of the population does not have coverage for one reason or another. A series of surveys were conducted in 2010 in Central Texas by the Central Texas Sustainability Project (CTSIP) to find out who had health coverage. They also asked follow up questions to those who do not have health care coverage to get the reasons why and to determine trends in their data.…
Throughout American history congress has had to resolve problems that arose nation wide. Pell Grants, created in 1972, and the Affordable Care Act of 2010 are just two of the legislations created to solve some of the United States economic problems. Although these two solutions were both initiated to boost America’s economy and to support low income families, the reason for the intervention of the government and their results differ.…
In the United States there are nearly 12 million undocumented immigrants that are denied affordable access to healthcare (Rosen, 2012). In 2010 President Barack Obama signed into law The Patient Protection and Affordable Care Act (PPACA) with the intention to expand economical healthcare to the millions of uninsured residents across the United States. However, this law excludes undocumented immigrants from receiving health insurance from the Marketplace, Medicaid or Children’s Health Insurance Program (CHIP) (D’Emilia & Suplee, 2012). The exclusion from the Marketplace, Medicaid and CHIP for undocumented immigrants furthers the gap of accessible healthcare as they are ineligible for governmental aid even though the foreign-born population has higher rates of poverty, lower education levels, and lower rates of health care coverage compared to U.S. born residents (Edward,…
Managed care is a type of system that was formed to help control the costs and quality to health care services; this will give access to services to specific groups of covered patients. The system was created to help the patients (customers) to receive services without having the full financial burden (University of Washington, 1998). The managed care services’ goal is to be able to help individuals and their families by providing health care services that is affordable. This type of managed care will help employees or individuals by requiring a set fee to be paid to the physician for visits, a co-pay and monthly premium to be paid to the insurance company. This will lower the amount that the patient has to pay. There have been many demands that have been needed in the managed care system; changes have had to be made to keep improving the health care services to help it to continue to grow. This paper will cover how the managed care began, in addition to how the system has grown and the changes of the system.…
The fee- for- services system was used in the U.S. until the twentieth century and, than advance payment was put into place to finance and, manage health care. The reasons for all the rising exposure to health care costs comes from hospitals that choose to become more advanced, have more new technologies which, increased costs onto the patients with higher premiums, patients paying more for services. Hospitals started using new technologies such as, new imaging devices, diagnostic machines, electronic patient filing so, this helped to transform hospitals in keeping up with the new trends, demands of industries and, demands of patients wanting more from hospitals and, getting services they needed yet, it increased costs as, the machines are costly and, hospitals have to have qualified staff to…