The highlighted language is a broad and material exception to the operation of Section 2.6. SelectCare is prohibited from denying a medically necessary claim under circumstances where good cause existed for the lack of prior authorization. This exception prevents SelectCare from unreasonably shifting the costs of its member’s medically necessary services to the Hospitals when the Hospital is not at fault. As discussed more fully below, good cause existed for the lack of authorization on each of the claims at issue. Accordingly, SelectCare’s denial of these medically necessary claims was unreasonable and payment should be made to the Hospitals.…
Medicare/Medicaid cuts continue with new costly and restrictive regulations. State and federal agencies are using new tools to redefine and recoup resources. Some days having a vision for the months ahead, putting the pieces together to bring about that vision and having a hand on the immediate issues/challenges seem an insurmountable task. Three years ago the State of Kansas decided they were going to save money by hiring “three middle men” to administer Medicaid funds. KanCare offers 3 privatized managed care plans for Medicaid recipients through a clearing house.…
The IG MPI Investigations Division conducts investigations of Medicaid providers regarding allegations of Fraud, Waste and Abuse in the Medicaid program. Referrals can come from: • Medicaid provider complaints. • Self-Initiated referrals based on information obtained from data queries, sister agencies, provider and community outreach or other external sources. • Financial audits which determine funds were not used as intended or which identify overpayments and disallowed costs.…
potential collaborative partnership with Cambridge Health Alliance o In negotiations with East Boston Neighborhood Health Center regarding potential sub-contract. o Obtained the following grants: Blue Cross Blue Shield Renewal grant =$40K; Health Connector Navigator=$150; John Snow Institute grant =$2.5; In-Kind City Benefits = $72K o Successful Fundraisers: Paint, Drink, Create & First Annual Wine & Cheese Reception o Conducted strategic discussions with external partners re. potential collaborative strategies o Rita and I presented at the CHA CHAC meeting regarding the Joint Committee’s work and the Affordable Care Act i. Meetings with Fred Foresteire, Charles Obremski, Janice Gauthier, and Jodie Lava re. potential collaboration between the Everett School Department and the JCCHCE ii.…
Due to Medica exiting the Medicaid Program marketplace. My organization Hennepin Health membership is expected to increase by at least 20,000 recipients. The adaptive challenges, my organization continuously faces is a delay in claims payment from our vendor TMG. An increased membership will result in an overflow of unresolved claims issues. The most difficult, challenge is we assigned new processes, due to an individual’s lack of claims knowledge or someone enhanced skilled sets.…
The end of the “separate-but-equal” provision of the Hill Burton Act, the Civil Rights Act of 1964, and federally funded Medicare and Medicaid have changed the way hospitals operate forever. Even privately owned hospitals could no longer continue the segregation and discrimination of people. They simply couldn’t afford loosing Medicare and Medicaid reimbursements, as well as the Blue Cross and Blue Shield plans that would no longer pay for patients unless the hospitals agree to comply.…
Agency Background Information The State of Tennessee Department of Health (TDH) received the name after many years of evolving through various roles and responsibilities of public health. In 1877 a bill was signed into law that created a State Board of Health to assist in organizing and improving the current health concerns during that time (“TDH”, 2016). In the 1800s, Nashville, Knoxville, Memphis and many smaller towns experienced life-threatening diseases that caused death and economic loss. The State Board of Health had obligations such as battling epidemics, creating county boards of health, improving the sanitation of schools, and maintaining vital records of births and deaths in the state (“TDH”, 2016).…
It's sad and very concerning that you may be suffering from the disease of addiction. However, it would be an absolute tragedy if you never got the opportunity to get the right kind of treatment so that you could have the opportunity to stop the madness in your life. Ultimately, it's your life that's at risk and the first step is yours. Setting Aside the Shame and Thinking About Substance Abuse Treatment Addictions are insidious diseases. They grab onto people at a time when those people are vulnerable and weak for a variety of reasons.…
With the Affordable Care Act, our healthcare system has been reformed and thus our state must be up to date with the innovations to address issues in…
Centers for Medicare and Medicaid services (CMS) is an agency under the Department of Health and Human Services (DHHS) that oversees the Medicare and Medicaid programs(Ferenc,2009). CMS became involved with the health care industry to separate obligations among the Center for Beneficiary Choices, Center for Medicaid Management, and the Center for Medicaid and States. And CMS must also respond to beneficiaries and taxpayers; what's more, CMS must confront the issues of a variety of political constituents, which include presidential organizations, congress, and groups exhibiting the health care industry. CMS is committed to dealing with our programs in…
Customer complaints are taken seriously and addressed accordingly for the company advocates emphasis on customer satisfaction. Urban large health systems, which serve as safety nets for the larger populations with a lower socioeconomic status and also whose most of the population speak English as a second language, do worse on government patient satisfaction than the smaller non-urban hospitals likely to serve white customers with higher educational level. Patient satisfaction is important and it is a key part in determining reimbursement levels to hospital by the Centers for Medicare and Medicaid Services (CMS). The ACA has encouraged hospitals to change from fee-for-service model to base care on measure of value and patient satisfaction. In addition, hospitals are rewarded or penalized on the standard that assess the quality of care of the patients.…
Even though the ACA expanded the coverage of Medicaid, it was only for “most low-income adults to 138% of the federal poverty level” (State Health Facts, 2015) thus, still leaving some of the economically diverse population, as they continue to fall through the cracks because they do not qualify Medicaid. In June of 2012, the decision of the Supreme Court authorized each individual state to make their own decision, as to whether or not comply with the ACA Medicaid expansion reform. Only thirty-one states have adapted the Medicaid expansion, as of September 1, 2015. This means that an average of “3.6 million Americans who would have likely received Medicaid coverage under the new rules remain uninsured today because they live in states that opted out of the Medicaid expansion” (Brodwin, 2014). This leaves the poor and Medicaid population being group stereotyped against because of the various states who did not embrace the voluntary expansion to help and assist the poor population and also, the Medicaid population who will face the challenges of locating medical doctors and facilities who are not accepting Medicaid recipients, which the government currently has no plans in place to detour this from…
Describe the roles, functions, and liabilities of the board in a managed care organization. The roles of the managed care organizations are used to reduce the cost of health care services through several forms of methods such as incentives that are useful through patient doctor relationships to develop a better form of care for the patients. “Gale Cengage Learning (2013) reports Managed care” refers to that type of health care system under which medical care and treatment is managed by the entity paying the bills, and not the medical care or treatment provider (physician, hospital, etc.). It is a system dominated by acronyms that identify different services or components, such as HMOs, PPOs, and EPOs.…
The health care system in aurora is important because many people depend of those services and it may affect those who do not have access. Residents who have access to health care are those with health insurance, Medicare, and also the affordable Care Act that benefit many. According to UC health benefits report, it states “UC health incurred nearly $185 million in uncompensated care cost in 2015 providing services to these patients and many of these new patients were newly insured through Medicaid which covered a portion of their care as a result of the increased availability of coverage through the affordable act.” This report examines the health system of UC health and how it has it has benefited many by offering new services to those who may not have access to paying health care…
A lot of the city’s population, however, fails to have sufficient hospital insurance. Our competition would include Webster Osteopathic Hospital, but they are not considered too much of a threat due to their small size. Middleboro Community Hospital has many specialty units, such as the Cancer Treatment Center, which would give them an advantage in attracting patients who live further away that are seeking specialized health care services. Gap…