A Case Study: Aetna Responded To North Texas

Unfortunately, Aetna’s compliance with the implant carve-out over the past five years has been anything but straightforward. By 2011, Aetna began to deny additional payment for charges billed using revenue code 278, despite its contractual obligations to pay the Hospitals for other implants billed using that revenue code. Instead, Aetna appears to be relying on an internal policy it has promulgated in an effort to unilaterally reduce its payment obligation for “Other Implants.” This internal policy, which is called the “Implants and Supplies Policy” (the “Implant Policy”), attempts to limit the implant carve-out payment to what the Implant Policy refers to as “Implantable Devices.” The term “Implantable Devices” is define by Aetna

This week I began my 6-week internship at Blue Cross Blue Shield of Nebraska (BCBSNE). The first day was a common orientation for all new employees, internally denoted to as the “onboarding process” where all employees are told they matter. This full-day session communicates the core mission, vision and goals of BCBSNE, organizational structure, operating objectives, and workplace culture. BCBSNE is a not-for-profit health insurance company that is focused on collaboration to find the best solution for their customers; in other words, they are customer-focused. Since the implementation of the Affordable Care Act (ACA), many changes to the health insurance market required a change in the organizational structure and culture of BCBSNE. Through partnerships with providers, the goals of BCBSNE are to be responsive, accountable, minimize errors, and decrease costs – all components of the ACA. BCBSNE has strategically aligned their goals to those of the government-mandated goals, and implemented them at all levels of the organization, making them competitive in the health insurance market. I found this very fascinating: I was very excited after day one!

The North Texas State Hospital (NTSH) is part of the Department of State Health Services (DSHS) administration. NTSH is a mental healthcare facility that has two campuses: one department is located in Wichita Falls, TX and the other in Vernon, TX. Including both campuses DSHS is the largest mental hospital in the state of Texas, which provides psychiatric services for the mentally ill. NTSH is the only facility in the entire state of Texas that provides forensic psychiatric care. Forensic psychiatric care is a specialized service for prisoners who have mental disorders. NTSH offers a 284-bed maximum security program for adults and a 78-bed adolescent Forensic Program (DSHS Center, 2017). NTSH aims to improve the health, safety, and wellbeing of individuals by providing the right stewardship, reducing health care problems, improving public health awareness, and preventing diseases. In order to improve health and safety, NTSH is accredited by the Joint Commission on Accreditation of Healthcare Organizations. The Joint Commission is an independent, not for profit association that set standards to evaluate

On July 12, 2012 Texas Governor Rick Perry nullified the Obamacare law in Texas. Going along with 26 other states decisions, Texas has refused in growing or expanding Medicaid with Perry stating that he would not bankrupt his state in direct contradiction to the constitution. Rick Perry had already stated his detest with Obamacare when he compared it with the titanic (Clabough, Raven 2012). Now the government was trying to make the states inforce and expand Medicaid, so of course Rick was not going to accept it. However, was it a really bad idea to refuse Obamacare or the best idea?

The ATRA and CALA are trying to stop minor cases from receiving enormous sums of money which will dampen the economy. The subject matter of these cases varies to some length including but not limited to medical and car insurance. In a case against Rich Mountain Nursing and Rehabilitation Center of Mena, jurors found the defendant, Mena, guilty of malpractice in the death of Margaretha Sauer, a ninety-three year old woman. The non-economic punitive damages cash award for the suffering and pain of the Sauer family to be paid by Mena was seventy-eight million dollars. Punitive damages is one of the issues that the ATRA is trying to combat. If nursing homes continue to have pay large sums for punitive damages, they will not be able to survive. The premium average liability offered by nursing homes has increased from $820,000 in 1999 to $11.6 million in 2001. With the liability premiums continuing to rise, the prospects of profits continue to dwindle. They will have no chance at retaining a profit and thus will have to close. It will also mean that doctors will charge more for their services, which leads to fewer health insurances carrying

On June 28, 2012, The Supreme Court ruled the Federal Government does not have the constitutional right to sanction an individual to buy health insurance, but declared that the states do have the right to place a tax on citizens that do not carry insurance. This ruling is in response to President Obama’s Patient Protection and Healthcare Act of 2010. Passed on March 23, 2010, President Obama’s Reform Act mandates Texas, as well as the nation, to provide Medicaid funding to all individuals that are uninsured by 2014. As well as expanding Medicaid, it will provide exchanges, which are pools of insurance companies a previously uninsured person can pick

Any decision naturally means there must be at least two options from which to choose. The decisions made concerning the Affordable Care Act (ACA) are certainly no exception. Certainly politics enters into the mix, as does associated costs, availability of medical care, quality of care and numerous other factors. While the idea medical care for all seems quite simple on the surface, the devil is in the details. My father, Dudley Plaisance, worked in healthcare for many years, even co-founding a company whose role was to find sources of funding for patients without resources to pay medical

In every day life one must make decisions, and with decisions there comes options from which to choose from. One decision from Texas that has caused concerned has ties to one of the provisions in the Affordable Care Act. This provision wants to expand Medicaid coverage to low income Americans. However, the Supreme Court ruled a decision to make the Medicaid expansion optional for states. Therefore, Texas opted out on this idea but is still indecisive on weather or not this expansion is beneficial to the state. As we all know factors like politics enter into the mix, as does the costs of the expansion, availability, and quality of care for these new “enrollees”. The idea of medical care for all seems like a simple effective idea, but the effects overall is detrimental to Texas citizens like myself and my family, who doesn’t necessarily fit into this “mold” of the uninsured citizen the act is trying to attract. The decision Texas made to not expand, in my opinion is a reflection of all citizens who feel that they will not benefit from this implicated Medicaid program.

Based on my analysis, both organizations do not have the capacity to manage change, however, out of the two, Middleboro Community Hospital is a little better. Both organizations are suffering from drastic leadership changes where people are either retiring or leaving. Having a strong leadership is the first step towards change management and both do not have that. MCH, however, has the support of its Board of Trustees due to their keen involvement in the operations of the hospital. The executive team meets with the President weekly and tours the hospital. Whereas, at Webster Hospital the team meets twice a month. MCH leadership and Board of Trustees are more involved and collaboratively work on the strategic plan. Webster Hospital is at OMC’s

Cross-Complainants are informed and believe, and thereon allege, that Cross-Defendants had no intention of completing the reconstruction improvements within the amount approved by the Bolanos’ insurance company. With the Home Improvement Contract, Cross-Defendants submitted an estimate for $275,718.08. When the Bolanos’ insurance company only approved repairs for 251,569.81, Pedro Luis Hidalgo made representations that all insurance companies approve less but that Cross-Defendants know how to obtain the difference between the requested and approved amounts.

Health insurance and the affordable care act is a major topic in the United States today. This being said, there are many questions that run through one’s mind when the topic is discussed. Questions such as, what exactly is health insurance? What is the Aetna-Humana merge, and how beneficial is it? Should healthy citizens help pay for citizens with prior known health issues? Should people with preexisting conditions even have the option to purchase insurance to help cover medical cost? Although the Affordable Care Act has been in effect for a few years now, there are still some problems today the health insurers face because of this law.

Communication between nurses at report change is essential. The next nurse needs the most important information whether it is as Situation-Background-Assessment-Recommendation (SBAR) that the Institute for Healthcare Improvement (n.d.) outlines to use or in another form. The case of Rio Grande Regional Hospital Inc v. Villarreal discusses how one nurse breached the standard of care because the record reflects that from the time Hermes was given the double-edged razor until he died neither Nurse Bergado nor any other nurse checked to see how Hermes was doing in the bathroom” (Find Law for Legal Professionals, 2016). At Baylor Scott & White at All Saints, we have a policy that each patient is rounded on physically every hour.

There are different types of insurance plans that will meet the different needs of the consumer. The different plan types will provide various levels of coverage for care that consumers can get in and out of the plans network of doctors, hospitals, pharmacies, and other medical service providers. Prudential (my choice to discuss) sold its HMO, preferred-provider organization, indemnity health and dental line to Aetna, making Aetna that largest managed care company (managed care, 1999).

Settlement packages were agreed upon and were very generous, including two years' worth of salary and benefits for outgoing employees effective beginning July 1, 2006. However by December 31, 2006, the financial statements indicate that the entire $900,000 has been expensed, when only the amount expensed between July 1, 2006 and December 31, 2006 should have been reported. The rest should be reported over the following 18 months of the settlement agreement, and not all at once. The ultimate result of expensing the full amount of the settlement before it has been paid misrepresents total net income by making it higher than it truly is, which leads to a lower ROA. As Paul's lawyer it would be beneficial to exploit this point and argue that by representing net income in the way that they have, Acme is making Extreme's ROA lower than it would be if the benefits were accrued properly.

Another aspect of the negotiation that could have been changed, resulting in a more effective and symbiotic outcome, would have been the number of years the terms included. If the agreement had, instead, called for an annual or bi-annual renegotiation, then perhaps neither organization would have been prompted to sue. Instead, they may have simply waited out the shorter termed agreement and renegotiated the terms or cancelled the agreement afterwards.