As my MBA concentration is in General Business and Finance the most relatable to my…
This firm represents North Texas Division, Inc. and its affiliated facilities, including Medical City Dallas Hospital (“Medical City”). Reference is made to the Medicare Advantage Facility Participation Agreement (eff. October 30, 2010) as amended (collectively, the “Agreement”). I write regarding SelectCare’s failure to appropriately adjudicate a claim by Medical City for services provided to patient E.F. By this letter, the Hospitals invoke all dispute resolution procedures permitted or required under the Agreement.…
The case involves treatment with bills for $313,210.00, where the insurance carrier only paid $29,719.08. The demand on the case was initially $150,000.00. The judge noted that a reasonable figure for settlement would be around $70,000. There is potential for settlement in the near future. However, there was some uncertainty regarding who’s our client, since the application was filed under Dr. Cox. I talked to Dr. Ghobadi’s office (which Andrew thinks is the owner of the receivables), and then Cornell Medclaim to figure out the problem. I spoke to Lou from Cornell Medclaim…
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.…
In Healthcare, the definition of quality can be difficult and debatable because of the diverse assessments of individuals with a stake in decent Healthcare. Let’s glance at a few different stakeholders. The stakeholders are broken done into three categories, internal, interface, and external. The internal stakeholders consists of the management (Human resource manager, Clinical managers, Pharmaceutical managers, Engineering, etc.), non-management (nursing, environmental…
If a patient visits a specialist but did not receive the required authorization prior to the visit, the claim may be denied, resulting in the provider’s need to appeal the claim (Jacob, 2001). Healthcare employees who handle billing and claims must be certain that all of the information they have for each patient is correct and up to date, and that they receive all necessary authorizations prior to performing any procedures. Additionally, insurance clerks have to be certain that they are using the proper procedure codes and not unintentionally over coding. Should a claim be denied, no matter the reason, it must follow the three steps of the appeals process. These three steps are complaint, appeal, and grievance. By filing an appeal, the claim can be paid when it was previously denied, reduced, or down coded. After the appeals process and decision, if a provider or patient is still not satisfied, the appeal can be taken to an outside authority, like a state insurance commission…
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.…
Despite the struggling economy across the nation, UnitedHealthcare businesses soared in growth and increased their year over year revenues by 8% in 2010. They widened their customer base by 1.2 million individuals. The economy turmoil was a significant reason for the growth in Medicaid program participation rising almost 15% from year to year. Additionally, the aging “baby boomer” generation contributed in the spike of 16% in Medicare Advantage consumers in 2010.…
Managed care is any arrangement in health care in which an organization like HMO or…
You will be given quotes from texts we have read and asked to identify and explain the literary device used.…