Additional know Summary: When family doctors clearly inequitable Medicare reimbursement formulas, Wisconsin and many other states punished for years. Reducing inequalities in health insurance payments is one of my priorities in the U.S. Senate. That is why I am so pleased that the Senate in July Benefit Prescription Drug Bill, S. 1 equity Medicare provisions, as an important step towards reforming the reimbursement rate for Medicare is include’m disappeared.
Source Product DescriptionThe most comprehensive inpatient coding and reimbursement, coding and reimbursement for patient services provides educators, students and practitioners in the health sector with the relevant guidelines for the management of patients hospital coding and reimbursement issues. The must-have resource has been designed to facilitate access to the most updated information you need for inpatient coding and reimbursement. Save time and effective decisions in this unique resource. You get a thorough understanding of: – methods of reimbursement for inpatient services – The structure and organization of the health insurance system for acute care inpatient prospective payment – The relationship between coding and DRG assignment – Data quality and compliance process to codify coding and reimbursement for inpatient services related to coding and reimbursement for patient services lays the foundation for learning and managing the costs of coding and reimbursement for inpatient services.
At this time of year, many snowbirds are preparing to take flight down south to escape our cold and snowy winter. Or, if you are not lucky enough to be a snowbird, you may be planning your winter vacation. As you pack your warm-weather clothing, you should also turn your mind to taking measures to protect yourself in the event that you have an out-of-country medical emergency.
A few days in a hospital in Ontario may cost your family some parking expenses incurred when they visit you, it will probably cost you nothing more than perhaps hiring someone to feed your pet or water your plants. A few days in a hospital in the United States, where costs can be up to $4,000 per day, may lead you to file for bankruptcy. OHIP will cover a percentage of this bill, but, the maximum amount they will reimburse you is the comparable cost of the expense had it been incurred in Ontario – which is about 10% of what is charged in the U.S.
The purpose of a travel insurance policy is to provide coverage for sudden, unexpected and unanticipated medical emergencies. A travel insurance policy is a smart purchase, however, before you buy one, you should beware of the limitations that are typically set out in these types of policies. Many travelers do not realize until after the emergency has occurred that their insurance may be null and void from the outset, or, that the insurance company may deny a claim for reimbursement because the policy is laden with exclusions and conditions. An insurance company will deny a claim in one of three situations: (a) your emergency medical care was related to a pre-existing (i.e. pre-departure) medical condition, (b) there is another exclusion in the policy that negates coverage, or (c) you made a “material misrepresentation” when you completed the application form.
The Application Process
Travel insurance is a form of retroactive underwriting. Typically, you complete an application for insurance and, more likely than not, you will be approved for coverage. This does not, mean, however, that the insurance company will reimburse you in the event you incur out-of-country health care expenses. “Approval for coverage” only means that the policy is now in place. It is only after you have become ill while on vacation and later submit your medical bills to the insurer, that the insurance company does its investigation into whether you are entitled to be reimbursed.
It is the application documents that unwittingly trap most people. Often, these application forms are no more than one or two pages and ask you very broad questions about your prior medical health. The Application Form itself may be worded very simply, and it is your answers that lead you to an accompanying page that sets out the conditions for coverage (i.e. the terms you have to satisfy before the insurance company agrees to pay your bill) and exclusions (i.e. the circumstances under which the insurance company will not pay for the medical expenses).
Pre-Existing Medical Conditions
The exclusions in most policies are usually written in small, dense print on the back of the Application Form or in the policy booklet that is provided to you after you have paid for the premium. By this time, most people do not bother taking a comprehensive review of the booklet.
The exclusion for pre-existing medical conditions is the exclusion that causes the most difficulty for travelers and is the main exclusion that ultimately leads to a denial of coverage. This type of exclusion is worded in various ways. For example, the Application Form may say that the policy will not cover:
“expenses incurred that are directly or indirectly related to a medical condition for which you have seen a doctor, have had treatment or been prescribed medication, in the last 12 months.”
“expenses incurred for a medical condition for which you sought treatment for a related condition in the 12 months before your departure date.”
“health care costs incurred as a result of a reasonably anticipated medical condition.”
“expenses for a medical condition for which symptoms occurred or which required medical consultation, treatment or prescription medication in the 120 days preceding your departure date.”
These exclusions are so broad that they allow the insurance company to rely on them quite easily. I have underscored above some of the more ambiguous and catch-all terminology. “Indirectly related” medical conditions can catch almost any pre-existing medical condition. Who decides what constitutes a “related” condition? Will a brief visit to a drop-in health clinic for a passing ailment be considered a “medical consultation” so as to exclude coverage? Would someone who has had high blood pressure for many years, but is otherwise in perfect health, be denied coverage for medical expenses incurred as a result of a heart attack in Florida, on the basis that the high blood pressure is “indirectly” related to a heart condition – even though it is no more than a risk factor? Or, would the fact that you had had a bout of bronchitis 12 months before your trip, for which you took antibiotics and then made a complete recovery, but were then hospitalized with a collapsed lung, allow the insurer to take the position that you sought treatment for a prior lung condition and as such the hospitalization costs will not be covered by the policy?
All of these examples may sound absurd, but they do happen. So if you are applying for insurance, read the Application very carefully and make sure you are aware of all terms and conditions before you pay the premium. If you see similar wording as I have provided above, ask the insurance company, and your doctor, for clarification.
Other Exclusions
There may be other exclusions unrelated to prior medical conditions that will allow the insurer to refuse to reimburse you. You must read and understand these exclusions so that you may purchase additional or supplemental coverage before your trip. Exclusions that may be overlooked, and could be detrimental, include:
The policy may provide coverage for hospital treatment only, and not for treatment in a medical clinic.
The policy may cover hospital expenses only where a person is admitted for at least 48 hours (or 24 hours, depending on the policy).
The policy may require advance authorization from the treatment provider before the insurer will agree to pay for the medical expense – this is deadly where you have to undergo emergency surgery and the hospital does not have your insurance information or is unable to contact the insurer.
The policy may provide you with a list of medical conditions that, based on your age, length of trip or destination, are not covered, irrespective of your pre-travel medical history. You may not even realize that you are not covered, because you are unfamiliar with the medical terminology used on the application form or in the policy booklet. Do you know what a transient ischemic attack is? How about cerebral vascular disease?
When in doubt about the meaning of any clauses in the policy or Application Form, ask your insurance agent, your broker, or the person who is selling you the travel insurance, for further clarification.
Material Misrepresentations
If you provide information to an insurance company at the time you apply for insurance, and the insurance company relies on that information in deciding to extend coverage to you, but later learns that the information was wrong or incorrect, the insurance company can declare the policy null and void. A failure to disclose pertinent information is called a material misrepresentation. With travel insurance, the Application Form usually asks you questions about your past medical history. This is where most misrepresentations occur, although in my experience they ultimately are not necessarily “material.” If you later make a claim for expenses, the insurance company will seek to obtain your pre-travel medical records and review them to ensure that you have not made any material misrepresentations.
Some people may forget that they had a mild heart attack 10 years ago, or that they once had blood tests to rule out a certain disease, or that they once suffered from a mysterious skin ailment. Thus, they fail to disclose these long-forgotten episodes on the Application Form. Or, the Application Form may use medical terminology foreign to the average person, for example, many people do not know what a myocardial infarction is (it’s a heart attack), so they fail to reveal the heart attack to the insurer.
A misrepresentation or failure to disclose is a valid basis for denying insurance coverage only where the misrepresented information is related to the medical emergency for which the person is seeking coverage. If you are travelling and become seriously ill with pneumonia and require hospitalization as a result, the fact that you failed to disclose a prior heart attack may prove to be immaterial. However, the insurer will try to argue that it has a right to declare the policy null and void, and, until the matter is resolved, the foreign hospital and/or its collection agency will be chasing you with its unpaid bill.
Tips and Advice
The bottom line? If you need a magnifying glass, dictionary or instruction manual to assist you to read the Application Form and accompanying exclusions, it is inevitable that you will not completely understand all the exclusions attached to the policy, you may make an error, and you may find yourself without reimbursement if you have an out-of-country medical emergency. There are ways to protect yourself so that you do not have to file bankruptcy, re-mortgage your house or start a lawsuit.
Read the application form and policy booklet very carefully before you pay the premium,
Go through the medical questionnaire with your doctor, especially if you are over age 65 and/or have a history of medical problems,
Do not buy a policy online, and do not shop around for the cheapest premium,
Purchase travel insurance through an insurance agent or broker. They will then bear the onus of explaining all exclusions and policy conditions to you and ensure that you understand them,
Do you have health insurance through your employment? If so, find out how much that policy will pay for out of country medical expenses. See if you can purchase supplemental coverage.
Claim all the benefits
Following are the points to be kept in mind:-
For Cashless claims
- When you opt for a cashless policy, the insurance companies have a tie-up with various hospitals all over the country. So you can avail of the cashless treatment at these hospitals. You can get this list either on their websites or with the policy documents.
- For an emergency hospitalizations, the third party administrator (TPA) should be contacted within 24hours. But if you are aware of the hospitalization then the TPA should be informed 3 days in advance.
- Once you are admitted in the hospital you need to fill up the cashless request form and get it verified and certified by the hospital doctor.
- After the form is completed then you need to fax the document with medical records to the TPA.
- When the documents are received by the TPA he accordingly informs the hospital to sanction the cashless request or asks for more documents if needed.
- On receiving the cashless facility the hospital bill is cleared by the insurance company and the policyholder does not have to bear any charges (subject to the policy limit). Only certain things like food, attendant charges or telephone calls are to be paid by you.
- Even if you choose to get admitted in a hospital which is not listed with the insurer you can still claim or get reimbursed.
Always remember to carry your health card which mentions your membership number and is known to the TPA so you can get your cashless benefit.
For Reimbursement of claim
Reimbursement of a claim can be done at hospitals which are affiliated or non-affiliated. Once you have availed the treatment, you have to settle the bills with the hospital directly and then file a claim with the insurer. The insurer must be informed within 7 days of the date of discharge. Through the insurance company website one can inform them of the policy certificate number and the claim as well.
Following are the documents in original are to be submitted to the insurer within 30days of discharge:-
• Completed claim form with the doctors certificate
• Discharge details.
• All the bills and receipts (including any advance and the final receipts)
• Doctors prescriptions for medicines and advice for laboratory tests
• Diagnostic test reports, X-ray, scan and other films
Claims get processed once all the documents are received and if any additional document required the company will inform the policyholder. After which the cheque amount is sent directly to the policyholder. If the claim is rejected the reason for doing so is informed to the policyholder as well.
Do’ and Don’t for reimbursement claims:
• Always get the original discharge documents and reports from the hospital.
• Copies of lab reports should be kept for future medical follow-ups.
• To be on the safe side keep photo copies of all the documents before you submit it to the insurance company.
•See that the receipts you get from the hospital are clearly numbered, stamped, signed and sealed.
• All the prescriptions and lab tests should be kept carefully as these are required to be given along with the claim form.
• If you are hospitalized for a traffic accidents make sure a complaint is lodged with the police and you get the copy of the FIR.
Normally we hear that most of the claims do get rejected. This could so as there could be illnesses which are not covered under the policy. So while availing of a health policy, always confirm the inclusions or the list of diseases which the company may not cover.
Disclaimer: Please note that the information provided is collected from sources publicly available & we believe to be reliable. The website doesn’t warrant the accuracy, reliability & absolute information available on the website. Participation by site visitors or registered customers is on a voluntary basis. The policies are offered by various life Insurance & non-life insurance offering companies and Bimadeals does not seek to, either directly or indirectly, advise, offer, solicit or recommend that any person who is or proposes to become its member should purchase the Policy.
From: www.bimadeals.com
At times, my company struggles from lack of cash flow. How significantly is our lack of working capital going to affect my business in the long-term?
Very significantly. Working capital is the readily available funds needed to run your business. It’s the money you use to meet your payroll and overhead, manage inventory and can be used to invest for growth and expansion. Having adequate working capital is the difference between long-term success and short-term stress. The lack of it leads to cash-flow problems, lost sales or missed expansion opportunities.
DME/HME providers can use working capital to cut costs. Your vendors, suppliers, and distributors generally offer discounts for increased quantity purchases and/or cash payments. By taking advantage of these reductions, these savings directly hit your bottom line. Or you can use the savings to upgrade your internal systems or streamline your operations, improving efficiency and increasing profitability.
Another benefit of having sufficient working capital is ensuring you have adequate inventory on hand to take advantage of sales opportunities. Suppose you just delivered your last unit and don’t have the funds on hand to replenish your inventory. How much business might you lose because you could not deliver? Or how much added business could you generate by using your discounts to be more competitive in your pricing?
For DME/HME providers, having adequate working capital is especially critical because of third party payor reimbursement delays. Traditionally, you acquire working capital through cash flow generated by your revenue stream, or funds are obtained through debt or equity financing. However, another financial tool increasingly being used by providers is Medical Accounts Receivable (MAR) Funding, the purchase and sale of your accounts receivables. It lets you convert a “non performing” asset from your balance sheet into the working capital you need, within 24-48 hours of billing third party payors. With MAR funding, you can generate a steady and predictable cash flow for your company without debt or ceiling caps.
Today healthcare providers must continually evaluate their current financial strategies to insure long-term success. Medical accounts receivable funding should be a key tool in that process.
Today’s world is a world of competition. You will find tough competition in almost all business industries. Nowadays medical transcription industry is growing as fast as anyone. Therefore healthcare professionals want their medical reports to be translated into text format in order to save time and money. Here, Medical transcription process comes into play.
Medical transcription is a process of writing whatever the doctor or medical practitioner says in a text or document format after doctor examines the patient. These pre-recorded medical words from healthcare professionals are translated in the form of a document or any other text format by professional medical transcriptionists. This process can be done at any place according to the medical professional’s convenience by using remote transmission technologies. It saves precious time of doctors and helps them in concentrating on their practice.
Medical transcription services provide number of advantages to Medicare companies, such as:
Even in hospitals, they have to keep necessary documents of patients or say they have to maintain medical records. Medical transcriptionist transcribes dictations or recordings into a text record. These are then maintained in two ways, either as soft copy or as hard copy. But in today’s IT enabled world, soft copies or EMR (Electronic Medical Report) are more used than traditional medical documents as they are easier to maintain.
Medical transcriptionist is responsible for creating these reports. So it is obvious that he must be very well aware of medical terminology. He should be careful that medical records prepared by him should follow medical transcription standards. Some of these standards are AHDI (Association for Healthcare Documentation Integrity), MTIA (Medical Transcription Industry Association) etc.
In medical transcription process, medical transcriptionist also takes care of current medical industry. He constantly updates himself by researching latest medical tools, medical language and equipments. Thus he keeps providing best results to medical professionals and medical companies.
Looking for the right health insurance company for your needs can be a very tough order. If you have been collecting information from a number of health insurance companies, you may be more than overwhelmed with all the information that has been presented to you. Instead of throwing it all aside and hoping there will come a day when you can sort it all out, you should start with doing some work from your side before you try to understand what they are trying to sell to you.NecessitiesThe first thing you need to know about health insurance is what your necessities are. If you don’t know what you need from an insurance company, it doesn’t matter how many pages of health insurance material you read, you still won’t know what you need. Start by making a list of the things you want to get from your health insurance. Do you want low deductibles so you have less out of pocket? Maybe you want to be able to stay with your doctor? Whatever your needs are from a health insurance plan you should have this list set and ready to go.Where Are TheyLocation is very important when it comes to health insurance. While you may not realize it, the offerings of insurance companies differ from state to state. Most of the reason is that there are different laws dictating what insurance companies can and can’t do in various areas of the country. This means you need to make sure the insurance companies you are considering actually serve your area, or you could be wasting your time.Claim ProcessHow are the claims for the insurance filed? Most companies have your claims filed automatically through the doctors office so all that you get is a rundown of services rendered at the end of the month and what they paid out. However, not all insurance companies run like this. Some want you to pay for the services up front, submit a reimbursement request and then get paid back. This is not only a lot of paperwork, but can be a financial hardship if you have a lot of medical bills to pay.Try It OutBelieve it or not, you may be able to try out a health insurance plan for a few months without being locked into a commitment. Think about all the industries that offer an introductory trial period. Once you start to find the insurance companies you think are best for you, ask about the possibility of a trial period. While you will have to pay the premiums during this time, if you don’t like the coverage you are getting, they will then let you out of the contract and you can find a better option.
As a healthcare professional, it is no longer simply go after orders. All professionals who care for patients with wounds are now being detained to a standard of care, and may be held liable for providing wound care of substandard quality, regardless of whether they believe they are covered by a physician’s order. Consequently, wound care practitioners need to be aware of these standards in order to protect their patients and avoid legal issues and denial of reimbursement.Legal issues involving wound care management are generally an issue of carelessness, or failure to meet the standard of care. Malpractice can be defined as failure to meet standards of care that results in hurt to another person. Health care professionals may be held legally responsible in the event it is determined that standards of care have not been met, and may be guilty of malpractice if a patient under their care is harmed.What may be the standard of care in wound healing management? Standards of care can be defined as the care that any reasonably cautious health care provider would provide in the same or a similar situation. Standards for wound care practice have been resolute by several sources: • Agency for Health care Research and Quality – the Agency for Health care Research and Quality (AHRQ) has specify guidelines for the prevention and treatment of pressure ulcers.• Patient Care Partnership – the patient care partnership includes basic patient rights, one of which is safe and secure, quality care.• State nurse practice acts and guidelines – these acts regulate the practice of nurses, and classify which treatments and actions may be performed by the nurse in each state.• Employer policies and procedures -policies and dealings are used to establish standards of care, and may be invoked in litigation claims-such claims may reflect either lack of information or blatant disregard for a policy, and may show negligence.• Job descriptions – health care employees who grant care outside their formal job description may be held liable.• Standards of practice – various professions have individual standards of practice, put by the professional organizations.
1. What is cerebral palsy?It is a phrase that describes a group of disorders that affect the ability of a person to control their muscles. CP, as it often referred to, is a disorder of the brain that can cause a number of problems which may include:* Problems in controlling muscles * Problems with walking * Problems using one’s arms or legs * Seizures2. What are some of the medical mistakes that cause this problem?Although there is no one single cause , it may be caused by mistakes made by doctors or hospitals. This situation can be caused in a number of different ways which could include:* Excessive force used in the delivery of the baby including the use of forceps * A delay in the performance of a necessary C-section * Failing to recognize on a timely basis that the baby is in distress * Depriving the baby of oxygen during the delivery * Failure to order specific tests during pregnancy and/or not properly interpreting tests * Lack of oxygen to the brain or trauma to the head during labor and delivery3. If my child is suffering from CP what should I do?It is extremely important to have an experienced medical malpractice injury attorney who has expertise in the handling and presentation of birth injury cases.An attorney should be contacted immediately if one suspects that this condition was caused by medical negligence.4. How do I go about getting experts to help me with my case?Your attorney will be able to suggest a team of experts that can range from private investigators to doctors to economists to help develop your case.5. Who will pay the expenses of hiring all of these experts?In most cases, the law firm or attorneys will advance all costs and expenses of the case as they are incurred. Once the case is concluded, they would be reimbursed for their costs out of the recovery. In some states, even if there is no recovery, the client is still responsible for the costs and expenses of the case even though the client owes no legal fees. In other states, if there is no recovery, the client will owe nothing for the costs and expenses, which will be absorbed by the law firm or attorney.
Diabetes is a chronic condition that demands routine management and is often complicated by common illnesses like respiratory infections or gastrointestinal flu. To ensure appropriate payment from Medicare and commercial insurers, family practice coders must understand the intricacies of diagnosis for accurate diabetes coding, along with the guidelines governing diabetes education reimbursement, and factors that determine which E/M codes should be assigned for routine care.The most important fact about diabetes diagnoses that goes without exception – the requirement of a fifth digit. Most diabetes -related diagnoses may be found in the diabetes mellitus section of the ICD-9 manual. Exceptions include gestational diabetes and neonatal diabetes mellitus. Various classifications and complications are identified with the fourth digit. In addition, coders must add a fifth digit that identifies Type I or Type II diabetes and further indicates if the disease is controlled or uncontrolled. A lot of times, this information isn’t clearly noted on the encounter form. You’ll need to seek out the physician and pinpoint the specific information necessary to determine which ICD-9 code to assign. Diabetes coding is complicated until laboratory results confirming the diagnosis have been received. For instance, a patient may come in with symptoms that strongly suggest diabetes – dizziness, excessive thirst, frequent urination and a family history of the disease. These symptoms will trigger testing for diabetes.” Coders would assign the appropriate E/M code ( 99211-99214, office or other outpatient visit, established patient), along with glucose finger stick code 82962 (glucose, blood by glucose monitoring devices cleared by the FDA specifically for home use) or 82948 (glucose; blood, reagent strip), depending on the method the physician uses. Practices would report a code for urinalysis if one is done at that time. Your diabetes coding will be most accurate when you use these codes to describe the symptoms that would be linked to support medical necessity.
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