Question

LP04.1 ASSIGNMENT: Appealing Decisions

Your written response should be no less than two to three pages in length.

This problem is adapted from a real case history developed by the Center for Health Care Rights in California.
• What procedural remedies does the patient likely have under private insurance and under Medicare or Medicaid?
• Are they adequate?

Problem: Mr. H. was a diabetic and had severe ulcers on his feet. He was a member of an HMO, and his primary care physician had prescribed a treatment regimen that was proving ineffective. In response, the primary care physician offered Mr. H. an amputation below the knee that was his only option. Mr. H. went out of plan to a local wound care center that specialized in diabetic wound treatment where he was advised that vein by-pass surgery would likely take care of his problem. The HMO denied such surgery because Mr. H. referred himself to the specialist without permission. The HMO advised Mr. H.'s family that its utilization review department was reviewing the case, but that it would take at least a month to review. Subsequently, the HMO agreed to approve such surgery, but only if done by Mr. H.'s current medical group, which did not have any physician who had ever performed vein by-pass surgery. Mr. H.'s family asked for him to be transferred to a primary care physician at the medical group that staffs the wound care center. The HMO responded that although they sometimes approve such requests, they would not do so in Mr. H.'s case and that they had already granted enough of his requests. They gave as their reason a provision in the plan documents that prevent referrals outside the plan's network when the network's physicians have the capability to perform the required procedure.

Submit this assignment to the dropbox "LP04.1 Assignment: Appealing Decisions." You can navigate to this dropbox by clicking the “next” arrow at the top right of your screen. This assignment is worth 50 points and will be graded according to the scoring guide below.

Answer 1

Medicare coverage Part A is hospital insurance that pay for inpatient hospital stays,skilled nursing facilites,hospice care and some home health care..it is depends on eligible for premium-free medicare Part A if a person more than 65years or old and must worked at least 10years in social security/medicare covered emplotment
Medicare coverage B is a medical insurance that pay for outpatient health care expenses..
Medicare C is a medicare advantages,CMS approved health coverage option provided by private insurance under contact with CMS..
Medicare D is a volundary federal outpatient prescription drug benefit available to everyone with medicare..
Requirements to continue california health coverage the person will receive notification from calPERS four months prior to the age of 65..eligible for premium-fee medicare part A,the person must be enroll in medicare part A and part B by enrolling in medicare part A and part B..calPERs will work with the center for medicare and medicaid services(CMS) to get medicare information and automatically transfer to a calPERS medicare health plan..
HMO medicare managed care plan to get additional costs for procedures and treatment other than applicable co-payments when you receive services from the HMO's network of providers..if the person go to out-of-network doctors or hospitals,they have to pay for all services(except for emergency or out-of-area urgent care services).medicare advantages plans are restricted..to enroll in a medicare advantage plan,he must reside within the health plan's service area..The medicare advantage plan must submit your enrollment to the CMS for approval..
   CMS regulations do not allow you to enroll in a medicare advantage plan through more than one employer..Double coverage frequently happens when a member has coverage through calPERS in addition to an outside source..Person must choose one employer with whom to continue enrollment..medicare advantage preferred provider organization(PPO) plan includes benefits in all 58countries in california..members have access to all providers that accept medicare..no primary care Physician(PCP) selection required,and no referrals required to see a specialist,there is no annual deductible..Medicare advantage PPO plan should be submitted to the CMS for approval
Provider accepts medicare limits on fees for services will not adequate for Mr.H's case it can charge more than that limit..
Medicare private insurance coverage pays upto the limits of its coverage..the one that pays secondary payers pays if there are costs the primary insurance did not cover and the secondary payer(medicare) may not pay all the uncovered costs,if your employer insurance is the secondary payer..you may need to enroll in medicare part B before your insurance will pay..