saaking Uader Adverse Coverage Decisions by HMO fromreal case history developed
ID: 125269 • Letter: S
Question
saaking Uader Adverse Coverage Decisions by HMO fromreal case history developed by the Center tor n: Appealing is adapted rPa l had severe ulcers on his feet. He was a membber o an was a diabetic and Are s, the primary care physician offered Mr. Han am knee as his only diabetic wound treatment, where he was advised tha below the take care of his problem. The HMO denied such would likely H. referred himself to the special 's family that its utilizato take atnly it a month to revievw only if done by Mr. H' permission. The was reviewing Subsequently, the HMO it would take at least that I but approe any physician who had ever did moted for him to be transferred to ap peformed vein nt medical y farmilhe staffs the wound care center, a bypass surgery daft, the ch requests, they would not do so in Mr. H.'s case and that they MO responded that although they ohat soprove senough of his requests. They gave as their reason a provision in revent referrals outside the plan's network when the net scumensse the capability to perform the required procedure. that prevent Problem: Choosing Health Insurance learned so far, which of the following insurance plans do assuming each one costs the same? Defend your choice (both ections) with reasons drawn from these readings: From what you have rs the full range of medical care, subject to standard medical ental exclusions, without any deductibles or co-payments, all care at an HMO clinic where doctors are paid a bonus .Plan A: Covers saving money for a cludes mental health services, but covers the rest of the normal Plan B: f medical care, subject to a $250 deductible and 20 percent co-payment . Plan um of $2,000 per year. Your choice of doctor, but all expensive must be submitted for prior approval by the insurer to determine up to a maximum of $2,000 medical appropriateness. our choice of doctor, and no prior authorization requirement, but subject to a $4,000 deductible. using 5,000 specific categories of inclusion and exclusion taken from the latest per range up to a maximum , Plan C: Covers the full range of medical care, with no major exclusions and .Plan D: Coverage is defined in an approach similar to the Oregon plan, butExplanation / Answer
I personally prefer Plan C. Plan C covers full range on medical care and we have the freedom to choose the doctor. Since prior authorization is not needed, we can save lot of time and effort.
Plan C allows to access multiple hospital network which is very helpful for elderly and working class people. Plan C require least paper work and reference.
The reason for rejection of other plans are mainly because of the pre authorization process and the strict terms. Other plan are very specific about where treatment can be taken and also need reference.
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