Читать книгу Kelly Vana's Nursing Leadership and Management - Группа авторов - Страница 105

I was admitted to the hospital in December for what was later diagnosed as angina. After being stabilized in the emergency room, I was admitted to the cardiac care unit. A series of tests were ordered by my cardiologist to determine enzyme levels in my blood. This would show if I had suffered a heart attack. Blood was drawn every 8 hr for 24 hr. The news was good—no heart attack—until I received the bill. My insurance company said the enzyme tests for angina were frivolous and not necessary, and they would not pay. I had my cardiologist write a letter of explanation, saying the tests he ordered were routine for determining a diagnosis. After this second appeal, the insurance company rejected my payment claim again. After several more appeals, my insurance company ultimately paid the laboratory bill for these tests but would not pay the pathologist for his interpretation of the blood tests. It has now been six months since I received my initial bill, and the hospital and pathologist's office have turned my case over to a collection agency. They did not take into consideration the fact that I was appealing the bill. They wanted me to pay upfront and then appeal. That was not going to happen.

Kathleen A. Milch

Patient

Whiting, Indiana

Canadians have their choice of health care providers. In Austria and Germany, if a doctor diagnoses a person as stressed, medical insurance pays for weekends at a health spa. Canada does make patients wait weeks or months for nonemergency care, as a way to keep costs down. But studies by the Commonwealth Fund and others report that many nations—Germany, Britain, Austria—outperform the United States on measures such as waiting times for appointments and for elective surgeries (Reid, 2009).

Many gaps have existed in insurance programs in the United States, including incomplete health care coverage, need for copayments and deductibles, lack of provider choice, need for preauthorization, and other difficulties in maneuvering through the insurance company requirements. Copayments are a fixed health care fee paid by the patient to the health care provider at the time of service; this amount is paid in addition to the money the health care provider will receive from the insurance company. Deductibles are a predetermined out‐of‐pocket fee paid by a patient for health care services before reimbursement through health insurance begins to be paid. For example, if an insurance plan has a $50 copayment and a $1,000 deductible, the patient is responsible for paying the $50 at each health care visit plus paying the first $1,000 of health care costs, after which costs will be reimbursed as allowed by the patients' health insurance plan. Preauthorization requires that approval be obtained from the insurance company before care or treatment, such as hospitalization or diagnostic testing, is initiated if such services are to be reimbursed by the patients' health insurance plan.