Case study on health insurance

Case study on health insurance

A. Your uncle, John Smith, is going to turn 65 in three months He has purchased his own health insurance plan through an independent agent for over 20 years.He saw a commercial about Medicare on television and it suggested to the viewers that they visit https://www.cms.gov/.

Questions:

Discuss what steps you would take to help your uncle understand Medicare eligibility and benefits.

Identify the best option for Uncle John and discuss in your response.

B. Researchers studied the outcomes of appeals from 1998 through 2000 (Studdert and Gresenz, 2003; Gresenz and Studdert, 2004). The researchers abstracted information from 3,519 appeals lodged against two of the largest health maintenance organizations (HMOs) in the country. The enrollees were disputing the plans’ decisions.

Of the appeals, 1,774 were pre-service appeals (Studdert and Gresenz, 2003). Preservice denials occur before the services enrollees are seeking have been provided. The researchers classified the pre-service appeals into five types: out-of-network, contractual coverage, medical necessity, administrative issue, and not evident reason. Enrollees were most likely to win appeals in cases in which the reason for the denial was not evident (52.7 percent) or which involved medical necessity (52.2 percent). Enrollees were least likely to win cases involving contractual coverage (33.2 percent). Overall, enrollees won appeals in 41.9 percent of the cases.

Questions:

Research the web and find out the process for appealing health care claims in New Mexico.

Explain the steps that you would take to appeal a health care claim.

Questions:

Discuss two major reasons that Medicare administrators turned to the prospective payment concept for Medicare beneficiaries.

Discuss the benefits and disadvantages of the Prospective Payment System.

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