Healthcare Reimbursement and Billing Essay

Excerpt from Essay :

Health Care Reimbursement and Billing

Both Mrs. Zwick and Mr. Davis face significant issues in the presented scenarios. Mrs. Zwick has multiple considerations under Medicare Parts A, B and D, in addition to her hospital-acquired urinary tract infection. Meanwhile, Mr. Davis must address the severe time constraints and costs of COBRA in light of his job termination. These two scenarios underscore current difficulties and complexities of current health care in the United States.

Discussion of Mrs. Zwick's coverage under Medicare Parts A, B and C

Medicare Part A (often called "hospital insurance") (U.S. Department of Health and Human Services, 2011, p. 15) assists in covering inpatient hospitalization and skilled nursing facilities, hospice and home health care (U.S. Department of Health and Human Services, 2011, p. 14). There is usually no monthly premium if you and/or your spouse paid Medicare taxes while employed (U.S. Department of Health and Human Services, 2011, p. 28). However, if you have to buy Part A, you will have to pay up to $451 per month (U.S. Department of Health and Human Services, 2011, p. 28). Medicare Part A will cover Mrs. Zwick's 5-day inpatient hospital stay, including her semi-private room, general nursing, meals, and miscellaneous services and supplies provided by the hospital (Medicare Consumer Guide, 2012). She will pay a deductible of $1,156 and no copayment because this is within days 1 -- 60 of her benefit period (U.S. Department of Health and Human Services, 2011, p. 34). The skilled nursing home for rehabilitation is also covered because it is deemed medically necessary after more than 3 days of medically necessary inpatient hospital stay (U.S. Department of Health and Human Services, 2011, p. 35). In addition, according to the 21-day projected stay she would pay only $144.50 for the 21st day, as she pays nothing for the first 20 days (U.S. Department of Health and Human Services, 2011, p. 35). As the case facts indicate, she was sick 10 days into her stay and could not participate for a full week, or 7 days. Since she stayed total 40 days, on the face of it, she would have to pay $144.50 per day for 20 days, totaling $2,890.00 (U.S. Department of Health and Human Services, 2011, p. 35).

Medicare Part B, (often called "medical insurance") (U.S. Department of Health and Human Services, 2011, p. 15), generally assists in coverage for services of doctors and other health care providers, outpatient, durable medical equipment and home health care (U.S. Department of Health and Human Services, 2011, p. 14). For this coverage, Mrs. Zwick pays a monthly premium of $99.90 (U.S. Department of Health and Human Services, 2011, p. 29). Part B will cover her doctor's bills (U.S. Department of Health and Human Services, 2011, p. 36) and the walker she received upon discharge because it is durable medical equipment. For this coverage, she must pay a deductible of $140.00, and then she will pay 20% of Medicare's approved amount for the service (U.S. Department of Health and Human Services, 2011, p. 36).

Medicare Part D (often called "prescription drug coverage") (U.S. Department of Health and Human Services, 2011, p. 14), has variable premiums and generally requires the covered individuals to pay 20% of Medicare-approved drug costs (U.S. Department of Health and Human Services, 2011, p. 48). Part D will cover Mrs. Zwick's lab tests, prescription/IV drugs during hospitalization (U.S. Department of Health and Human Services, 2011, p. 14), as well as her prescription medications upon her discharge…

Sources Used in Document:

Ethical implications of Mrs. Zwick's incurring costs related to her hospital-acquired condition are applicable despite the rehabilitation facility's exemption from POA/HAC Medicare laws. Having no first-hand knowledge of the cause of the urinary tract infection, no clear indication that I work at the rehabilitation facility and neither the privilege nor the duty of diagnosis, it would be unethical for me to tell Mrs. Zwick about my suspicions. Rather, a nurse is required to maintain his/her professional boundaries (American Nurses Association, 2001, p. 6). Simultaneously, a nurse is supposed to assure "responsible disclosure of errors" to patients and act to stop bad practices and promote best practices (American Nurses Association, 2001, p. 6). Consequently, a nurse in my position faces a dilemma: lack of personal knowledge and authority vs. my concern for the patient's well-being and constant improvement of the profession. In the face of this dilemma, I would: contact the rehabilitation facility's newly-hired nurse and advise/remind him/her of the duty to report to the appropriate supervisor and responsible disclosure to Mrs. Zwick; contact Mrs. Zwick's personal physician and explain the entire situation; direct Mrs. Zwick to discuss her health issues with her personal physician, who can review, diagnose and discuss the ramifications of her medical records, including but not limited to the urinary tract infection (American Nurses Association, 2001, p. 7). The desired outcomes would be: the rehabilitation center's absorption of Mrs. Zwick's costs related to her hospital-acquired infection through pressure exerted by its own nursing staff and Mrs. Zwick's personal physician; Mrs. Zwick's awareness of the true cause of her infection by health care providers who are directly responsible and capable.

Explain how the COBRA will allow Mr. Davis to continue his insurance coverage while he is out of work.

Due to Mr. Davis' termination from an employer of more than 20 employees, he can obtain coverage for himself, his spouse and his dependent children for up to 18 months (U.S. Department of Labor, 2012). In addition, due to his chronic cycle cell anemia, he may be entitled to an additional 11 months' extension for disability (U.S. Department of Labor, 2012). His employer is required to give a qualifying event notice to COBRA; then, COBRA sends a notice of the right to elect to continue coverage and an explanation of the steps that must be taken to continue coverage; Mr. Davis, his spouse and either or both of them in behalf of dependent children may elect for continuation of coverage

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