Question

You are the CEO of Broadway Medical Center.  Mrs. Sarah Jones is admitted to your hospital preparing to give birth and in a great deal of pain. According to her medical records, her unborn child is suffering from a heart defect and must be operated on quickly to save the life of the child. The surgery that must be done is expensive and can only be performed by a pediatric cardiologist, fetal surgeon, and their medical teams. Mrs. Jones insurance will not pay for the care, and is currently in a legal battle over Mrs. Jones insurance status.  This surgery is extremely dangerous, risky, and will cost the hospital millions in the short term.  The fact is that there is only a 50% chance that the procedure will work.

Knowing all of this, how do you treat Mrs. Jones situation?

What are the legal and ethical issues?

How do you deal with the insurance company and reimbursement?

Can you put any pressure on the insurance company?

Answer 1

Knowing all of this, how do you treat Mrs. Jones situation? As Mrs. Sarah Jones need immediate attention, here as per the case, she is supposed to give birth and in a great deal of pain, also as per report her unborn child suffering from heart defect and must be needed very immediate action to save the life of the child, Irrespective of the cost, the surgery should be given prior attention, as there could be alternative way to recover the cost of health care services, again as Mrs. Jones found dispute for recovering the cost from Her Insurance package, so such Should be judged without compromising with the needed health care for Mrs. Sarah Jones, Again Medical Centers authority can check for alternatives by estimating the overall cost expenditures of her Surgery, thus such expenditure based on estimation can be covered from other cell like Not for profit Organization or any Institution who can provide the fund, but medical Center should not avoid such situation, rather look for alternative and keep no compromise with the health treatment for Mrs. Sara Jones

What are the legal and ethical issues? Ethical issue can come before both the Medical center and insurance company, if they are not able to justify the situation and manage the same in proactive manner, as this kind of situation can take out life of Child or her mother or even both, again legal debate can come over insurance issues of Mrs. Jones Insurance package, and any further wrong decision or decision which can drive negative impact, can lead to legal issues

How do you deal with the insurance company and reimbursement? Insurance company should pay the reimbursement based on the Bill is amounted and the policy of Insurance taken by Mrs. Sarah Jones, again giving them all supportive data and medical billing, estimation which can be regarded as claim establishment again the Insurance company, further, insurance company can process such billing amount with the help from Medical center,

Can you put any pressure on the insurance company? As a purpose of medical center, we should furnish all the estimated billing and claim procedure and such claim can be recovered with putting prior request to the Insurance company, again, Insurance company may release the fund as per applicable Policy, so for quick fund processing, pressure can be given, but the Amount of fund may depend on type of policy, so unnecessarily pressure can’t be processed, again Medical center also look for any other alternatives those can issue fund for such situation to recover the cost of Surgery by preparing correct information on Estimated billing