Pamene Inshuwalansi ya Umoyo Imakana Kuphimba PAM
Ngati mutangochotsa chala chanu patebulo, tawonetseratu kuti chipinda chodzidzidzi chiyenera kukhala choyimira chotsatira. Koma sikuti zonse zoopsa ndizovuta.
Zipinda zam'chipatala ndi malo okwera mtengo kwambiri ochiritsira kuchipatala, motero chifukwa cha mavuto omwe siwowopsa, athandizi amafuna kuti mamembala awo agwiritse ntchito malo ena ochepetsetsa, kuphatikizapo malo osamalidwa bwino kapena ofesi ya osamalira oyang'anira.
Odwala akamagwiritsa ntchito zipangizo zosakhala ndi ER, zimakhala zosawonongeka kwambiri kwa inshuwalansi, zomwe zimapangitsa kuti pakhale ndalama zambiri zothandizira odwala komanso kuchepa kwa inshuwalansi kwa aliyense. Koma ngati ali ndi vuto la moyo kapena lachiwalo, chipinda chodzidzimutsa chikhoza kukhala malo okhawo okonzekera bwino kuti athetse mavuto ena.
Ndipo conundrum ndi yakuti anthu ambiri saphunzitsidwa kuchipatala mwachangu, choncho ngati mukukayikira za vuto lalikulu lachipatala, kulakwitsa pambali yochenjeza (mwachitsanzo, kupita kuchipinda chodzidzimutsa) mwachiwonekere kumawoneka ngati njira yochenjera kwambiri.
Nthano imapanga mkangano ndi zatsopano MWA malamulo
Kwa mbali zambiri, inshuwalansi amalipira maulendo awo kupita ku chipinda chodzidzimutsa. Koma Anthem yatsutsana ndi malamulo atsopano ku Georgia, Indiana, Missouri, ndi Kentucky (yogwirizana pa July 1, 2017), zomwe zimasintha mtengo wa ER akuyendera wodwala ngati kubwereza kwa chigamulocho kumatsimikizira kuti zinthu sizinali zosautsa pambuyo zonse.
Wodwala wofalitsidwa ndi Vox anapita ku chipinda chodzidzimutsa ku Kentucky ndi kupweteka kwa m'mimba ndi malungo. Mayi ake, namwino wamkulu, adamulangiza kuti apite m'chipinda chodzidzimutsa, chifukwa zizindikiro zake zimagwirizanitsidwa ndi appendicitis , zomwe zimaonedwa kuti ndi zachipatala. Koma zinapezeka kuti anali ndi mavalasi m'malo mwake, chinachake chomwe chinangosindikizidwa pambuyo pa chithandizo chachipatala chinaperekedwa mu ER.
Anthem ndiye anamutumizira kalata ya ndalama zoposa $ 12,000, akunena kuti chigamulo chake chikanaletsedwa chifukwa chakuti adagwiritsa ntchito chipinda chodzidzimutsa chifukwa cha chisamaliro chosasamala. Wodwalayo anadandaula, podziwa kuti sakudziwa kuti ululu wake sunali wofulumira mpaka madokotala a ER atamupeza. Pambuyo pake, pambuyo pempho lake lachiwiri (ndipo atatha kufotokozera nkhani yake ndi Vox), Anthem anapereka ndalamazo.
Malipiro a ER Nthawi zambiri Amakhala ndi mutu
Malamulo atsopano a Anthem akukhudzidwa ndi odwala ena ambiri kudera linai. Koma ngongole zamankhwala zodabwitsa zomwe zimayambitsidwa ndi ulendo wopita ku ER sizatsopano.
Malamulo ena ali ndi malamulo ofanana a Medicaid omwe amalembetsa, ndi ndalama zowonjezereka zogwiritsa ntchito chipinda chodzidzimutsa (ngakhale kuti mukutsatira malamulo a Medicaid, mapepalawa amadziwikabe poyerekeza ndi mtengo wa chisamaliro choperekedwa mu ER).
Ndipo anthu omwe amadzipezera okha ku ER omwe ali kunja kwa mapulani awo a inshuwalansi amathera ndi ngongole zazikulu zamankhwala, ngakhale kuti ACA imafuna mapulani azaumoyo omwe sali nawo kale kuti asamalire chithandizo chodzidzimutsa ngati kuti malonda.
Izi zakhala zikuyang'aniridwa kale, ndi mabungwe a inshuwalansi kawiri kawiri kuti awonetsetse kuti chisamaliro chinali chenicheni chisanayambe kulipira ngongole za kunja ER.
Ndipo ngakhalenso ngati inshuwalansi ikulipira ngati kuti in-network, kunja-network-ER sikumayenera kulandira malipiro a inshuwalansi monga malipiro onse, popeza ER alibe mgwirizano ndi inshuwalansi, ndipo akhoza kuwonetsa perekani wodwalayo kuti adye gawo la ndalamazo atachoka. Ngati idafika pa intaneti, ER ayenela kulemba gawo la ndalamazo, pansi pa mgwirizano ndi inshuwalansi. Koma palibe zofunikira zotero za malo osokoneza.
Chikhalidwe cha chisamaliro chodzidzimutsa chimapangitsa ovuta kulumpha kupyolera mu inshuwalansi zomwe zingakhale zosavuta.
Muzochitika zosautsa, nthawi zambiri anthu amachititsa kampani yawo ya inshuwalansi kuti ifunse za chilolezo chisanayambe kapena yang'anani ndi dokotala wamkulu kapena a nuresi kuti awone chisamaliro chomwe akulimbikitsidwa. Koma pavuto ladzidzidzi-kapena zomwe zimawoneka ngati zovuta, kuchokera kwa wodwalayo-zinthu zimenezo zikhoza kunyalanyazidwa.
Ndipo kwa gawo lalikulu, umo ndi momwe ziyenera kukhalira. Ngati mwamuna kapena mkazi wanu akudwala sitiroko, simuyenera kudandaula za kuyitana kampani yanu ya inshuwalansi-mumayenera kuitanitsa 911 kapena kupita ku ER mofulumira.
Koma ogula amamvetsera nkhani za inshuwalansi akutsutsa ngongole za ER chifukwa chakuti inshuwalansi amatha kuona kuti palibe vuto, ndiye kuti ndikudandaula. Wodwala m'nkhani ya Vox adanena kuti ataphunzira zomwe adachita ndi ER adavomereza, adzalandira "ambulansi kuti apite nawo kuchipatala" kupita kuchipinda chachangu. "
Mvetserani Ndondomeko Yanu - Asanafike Mwadzidzidzi
Mukamadziwa zambiri za momwe inshuwalansi ya thanzi lanu imagwirira ntchito, ndibwino kuti mukhale okonzekera kuti mukhala ndi zochitika mukamaliza kugwiritsa ntchito zolemba zanu. Kotero, sitepe yoyamba ndiyo kuwerenga mosamalitsa ndi kumvetsa ndondomeko yanu. Anthu amakonda kuzimangirira mu kabati ndikuiwala za izo kufikira atagwiritsa ntchito izo, koma palibe nthawi yoti izi zichitike. Kotero, panthawi yomwe simukukumana ndi kusowa kwa chithandizo chamankhwala, khalani pansi ndi ndondomeko yanu ndipo onetsetsani kuti mumvetsetsa:
- Ndalama zowonongeka ndi zowonongeka pa pulani yanu, ndi mapepala alionse omwe akugwiritsidwa ntchito ku ER akuyendera (ndondomeko kuti mapulogalamu ena adzasiya copay mukamaliza kulandira chipatala kudzera mu ER, ndipo zifukwazo zingagwiritsidwe ntchito wanu deductible-izi ndi zinthu zomwe mukufuna kumvetsa pasanapite nthawi, choncho funsani kampani yanu ya inshuwalansi ndikufunsa mafunso ngati simukudziwa momwe dongosolo lanu limagwirira ntchito).
- Kaya ndondomeko yanu imapereka chisamaliro chatsopano , ndipo ngati ziri choncho, kaya mulipo kapu yomwe mumagula kuti musamalire. Kuonjezerapo, ngati pali ER m'madera mwathu, mukufuna kudziwa zomwe zili mu ndondomeko yanu ndi zomwe siziri, chifukwa sizinthu zomwe mukufuna kuti muzidandaula nazo panthawi yovuta.
- Kaya ndondomeko yanu ili ndi lamulo lomwe lingadzitengere kukana kudandaula kwa ntchito yosafunika ya ER. Ngati ndi choncho, dziŵani ndi chitsimikizo chanu cha inshuwalansi potsutsana ndi zosadziwika. Ngati malangizowa sakuwonekera bwino, funsani inshuwalansi kuti mukambirane nawo, kuti muthe kumvetsetsa zomwe mukuyenera kuzigwiritsa ntchito potsata malo omwe mukuyenera kugwiritsa ntchito. kwa mamembala mu 2017, pamene malamulo awo atsopano ku Georgia, Indiana, Missouri, ndi Kentucky atayamba kugwira ntchito).
- Zomwe zofunika za inshuwalansi zanu ziri zokhudzana ndi njira zamankhwala zam'tsogolo zomwe zimachokera ku kuyendera ER.
Kodi Muyenera Kuchita Chiyani Ngati Muli ndi Bill Yopanda Mwadzidzidzi?
Ngati mutenga bikulu yayikulu kuposa yodalirika mutatha kuyendera ku ER, pitani kwa inshuwalansi yanu ndipo muonetsetse kuti mukumvetsa zonse zokhudza biliyo. Kodi ndi bili yamalonda kuchokera kwa ER-ex-network-ER? Kapena kodi kukana kudandaula chifukwa wanu inshuwalansi amaona kuti mulibe vuto? Zakale zimakhala zofala kwambiri, koma komanso, mwatsoka, pamene wodwalayo alibe njira yothetsera vutoli.
Ngati mwalandira ndalama zamalonda kuchokera kuntchito yowonongeka (mwachitsanzo, wanu inshuwalansi adalipira mbali ya zomwe akunena, koma ER akukulipirirani zina zonse, ndipo sakulembera zolakwa zilizonse chifukwa musakhale ndi mgwirizano ndi inshuwalansi), pali zinthu zingapo zomwe mukufuna kuchita:
- Yang'anani ndi dipatimenti ya inshuwalansi ya boma lanu kuti muwone ngati pali malamulo otetezera ogula kapena malamulo anu omwe akukwaniritsa momwe mungagwiritsire ntchito ndalama zowonongeka. Palibe malamulo a federal omwe amalepheretsa kubweza ndalama kuchokera kwa anthu otulutsidwa kunja, koma ena amanena za vutoli .
- Ngati palibe chilichonse chimene dziko lanu lingathe kuchita, pitani ku-ER-network pomwepo ndikuwone ngati angakambirane nanu. Angakhale ololera kulandira ndalama zing'onozing'ono ngati kulipilira kwathunthu.
Ngati mwalandirapo chidziwitso chakuti malonda anu adakanidwa chifukwa wanu inshuwalansi atsimikiza kuti mkhalidwe wanu sunali mwadzidzidzi (ndipo mumakhulupirira kuti ndizochitika zosautsa kapena chimodzi chomwe munthu wanzeru angachiyese chodzidzimutsa), muli ndi njira zambiri zokhudzana ndi pempho:
- Ngati ndondomeko yanu siinabadwe, ACA ikukutsimikizirani ufulu wodandaula mkati, ndipo ngati inshuwalansi akutsutsabe zomwe mumanena, mumakhalanso ndi mwayi wopitilira ndondomeko yakunja ndi wina wodzitetezera (apa pali chidule cha momwe akufunira ntchito zothandizira).
- Mungayambe mwa kuyambitsa ndondomeko yam'kati mkati mwa bwana wanu inshuwalansi, komanso pofika ku dipatimenti ya inshuwalansi yanu kuti muwone ngati ali ndi chitsogozo kwa inu.
- Onetsetsani zomwe zimachitika panthawi ya pempho, kuphatikizapo mayina a anthu omwe mumayankhula nawo ndi mauthenga omwe mumalandira kuchokera kwa inshuwalansi yanu. Mudzafunanso kusunga chipatala kuchipatala, monga momwe angafunikire kuti apereke zambiri zowonjezera kwa kampani ya inshuwalansi kuti asonyeze kuti mkhalidwe wanu ukuyenera ulendo wopita ku ER.
- Ngati zopempha zakunja ndi zakunja sizikutha, mudzafuna kuthetsa vutoli ndi chipatala. Angakhale okonzeka kuchepetsa ndalama zawo kapena kukhazikitsa ndondomeko yoyendetsera ndalama.
Kusemphana Komwe Kudabwitsa Kwambiri Misonkho
Nkhani za zatsopano za ERM za ERM ku Georgia, Indiana, Missouri, ndi Kentucky zinakumana ndi kufuula kwa odwala komanso ogulitsa malonda. American College of Emergency Physicians anakankhira mmbuyo ndi kanema yomwe inalengedwa kuti iwonetse zolakwika m'dongosolo lomwe limapangitsa odwala kumvetsetsa zomwe ziri ndi zosayembekezereka, pamene zinthu zina sitingathe kuziyesa popanda kuyesedwa.
Anthem yanena kuti njira yawo yowonjezera ikuchokera m'zinenero zomwe zinali kale muzinkezi zawo, komanso kuti "chidziwitso chodziwika bwino" chakhala chikugwiritsidwa ntchito koma tsopano chikulimbikitsidwa (mwachitsanzo, ngati "munthu wochenjera" angaganize kuti ndidzidzidzi, ndiye kuti Ndizadzidzidzi). Koma momveka bwino, izi ndizosuntha. Odwala, opereka chithandizo chamankhwala, ndi ogulitsa malonda akudandaula kuti chizoloŵezichi chikhoza kufalikira kwa inshuwalansi yambiri, kusiya odwala osasamala (pa nthawi yovuta kwambiri) yokhudza kusamalidwa mu ER, zomwe zimachititsa zotsatira za thanzi laumphaŵi. Koma Anthem, ndipo mwinamwake ena a inshuwalansi omwe amatsatira, akugwiritsanso ntchito phindu la chithandizo chamankhwala-ntchito imene aliyense amagwirizana ndi yofunikira, koma ochepa amavomereza momwe angakwaniritsire.
Ndipo ngakhale kuti kukana kudandaula chifukwa cha kugwiritsidwa ntchito kosavuta kwadzidzidzi kwa ER kumayambitsa chisokonezo ndi nkhawa, vuto la madalali azachipatala osadabwitsa potsatira kuyendera kwa ER wakhala vuto lomwe lisanayambe ndondomeko yatsopano ya Anthem. Mayiko onse akhala akugwira ntchito kuthetsa vutoli nthawi zina, koma amakhalabe vuto m'madera ambiri m'dzikoli.
Ngakhale kuti zothetsera vutoli zikuwoneka bwino poyang'anitsitsa kuchokera kwa wodwala kapena wogulitsa malonda, ndizovuta kuti onse ogwira nawo ntchito apite. Kwa nthawiyi, ogula amafunika kumvetsetsa momwe angathere polemba momwe ntchito yawo ikugwirira ntchito ndi zomwe ufulu wawo wodandaula ndizo ngati atapeza ndalama zosayembekezereka atapita ku ER.
> Zotsatira:
> American College of Emergency Physicians. Madokotala Odzidzimutsa Awonetsa Pulogalamu Yowonongeka Yowopsa Kwambiri ndi Vuto Latsopano. January 17, 2018.
> Magulu a Medicare ndi Medicaid Services. Madandaulo a Pakati ndi Maumboni ndi Ndondomeko Yowonongeka Kwakunja. April 12, 2017.
> National Association of Insurance Commissioners, Mapu: Malamulo ndi Malamulo.
> Pollitz, Karen. Kaiser Family Foundation. Misonkho Yodabwitsa Yodabwitsa. March 17, 2016.