Escalation: Case Study

Rather than having the other claims adjusted, the provider insisted that we not look into the matter further because they did not want us to take back any money. Sadly this is just one example of fraud; it is not uncommon to see providers change the coding of claims to get something that they know should not be paid to process for payment. Cracking down on this type of fraud will reduce the amount of money paid out on claims by insurance carriers. Since claims payments directly affect the cost of insurance, this will also help in lowering premiums.

RESOURCE UPDATE: Client continues to report last week she went to Center 37 and she was told that her Center is now 066. Client was upset that she was transfer to another shelter. As per the client she will lose her Linc V if she is transferred to Center 66. CM tries to explain to the client HRA transfer many clients because Center 37 is overcrowded. Client reported she requested for her case to be closed. Client continues to report she spoke with HRA Rep Ms. Perez who requested for the client to put her request in writing. Client stated she did put her request in writing to have her case closed from center 66. Then the client provided this worker with copy

De-escalation Room:-Used for de-escalation for behavior that could potentially result in injury to self or others. This is not a consequence for behavior

SC received a telephone call on 10/16/2015 stared 9:34 and end at 9:41 am from Tricia Crooks at Liberty Resources Home Choices (LRHC) Community Outreach and Enrollment Leader. Stating that she spoke Pa and he wants to resume his service order with LRHC for PAS service. SC informed SC that this information will first need to verify with Pa. SC expressed concerns about LRHC being able to fulfill service since they had the case unstaffed for over two weeks (09/25/15-10/15/2015). Tricia apologized on behalf of LRHC, and stated that they have someone assigned and is ready to go all is needed is the resumed service order ASAP. SC again explained to Tricia that Pa has to confirm this besides Pa was very adamant about switching provider because the

You contacted me on 09/03/2015 stating that the provider wanted to speak with a supervisor. You stated the reason she wanting to speak with a supervisor because she wanted someone that “could understand her”. I probed you asking if their was a language barrier or a question that you were not able to understand. You stated to me that you explain the denial and you understand her clear but she still asked to speak with someone else. I ask did she asked to speak to someone else or a supervisor and you replied a supervisor. I advise you that I would be reviewing the call and providing you with feedback.

Violence in health care is an intriguing subject. Understanding and coping with threatening and violent behavior in mental health settings can be challenging and is a necessary part of being a health care provider (Berring, Pedersen, & Buus, 2016). If the situation is not handled well, patient and staff injuries can occur. A well thought out de-escalation plan and having a process in place is valuable. Having a range of psychosocial interventions that are focused on redirecting patients can help calm them down. The important aspects of de-escalating are being familiar with the patient, understanding the situation, knowing yourself, and having the knowledge of how to communicate in such a situation. Unfortunately, there are not many studies that have explored how staff and patients experience de-escalation methods and further research is needed in this very relevant area of health care.

Your grievance appeal has been reviewed at Central Office and the Deputy Bureau Administrator's response is modified. Pursuant to Department Order 802.01, GENERAL INFORMATION:

My office has completed the necessary steps to address the anomalous claim. My office is awaiting a response from your office to proceed with her request for a new claim.

In order to explore how a crisis worker would approach, assess, and treat a crisis situation, this paper will focus on the story of Melody, the victim of a brutal rape. Melody Swanson is a 50 year old, divorced teacher who has been living alone since her children went to college two months ago. Melody came home from a short vacation to the casino and was met in her driveway by an armed man in his twenties. She was abducted at gunpoint, beaten, raped, robbed, and left abandoned several miles from her home. Melody was able to find help and was

In your letter you claim that you submitted a Step II appeal on 01/15/2017, which was never received at Central Office. You were then allowed to resubmit your Step II Appeal and your time frames were reset. You state that to reset the timeframe is not in policy.

I am appealing for denial of my STD claim due to the following reasons. I submitted the claim on 07/22/2016. I was informed that within a couple of days my claim is going to be assigned to the claim manager, and the claim manager will discuss the following steps I need to take. A few days after I was contacted by Monique informing me that my treating physician will need to fax supporting information by 08/04/2016. I believe on 08/01/16 Monique reached out to me again stating that she has not yet received my information from my physician yet. According to my physician, the required information was faxed on 08/03/2016 and 08/04/2016. After these dates, I have not heard from Monique or my client manager Cheriane Zephy in regards to the progress or the approval/denial of my STD Claim. I reached out to Aetna numerous times trying to get in touch with my client manager. At every attempt, I was told by the customer service representative that my client manager either is away from her desk, cannot take my call, or out of the office for the day. Additionally, I was informed that according to their log, my client manager called me on 08/08/2016 and 08/09/2016, which is

De-escalation strategies, cool off area, movement breaks, preferential seating away from distractions, visual/verbal prompts and cue, behavior intervention plan, clear and direct instructions and expectations, check for his understanding of classroom and assignment expectations, extended time (time and a half for classwork and assessments and at staff discretion), reduced class assignments and homework, shortened school day, chunking of assignments (task analysis and present 1-2 steps at a time), allowance to write on clipboard backed up away from desk, noise reduction headphones/ear

This case was the last appealed case of the series and therefore, no other actions followed. This is because the judge affirmed the case as “an order sustaining demurrer without leave to amend”. This statement means that the plaintiff cannot amend the complaint.

Pa is receiving the amount of support necessary to ensure her health and safety needs are met and Pa remains satisfied w/ her services. SC reviewed backup plan w/ Pa, Pa's Cousin Linda, will assist if PAS is not available. This is a new backup plan for Pa. Pa is currently using backup plan until the agency aide starts. SC provided and reviewed the "Who do I contact if. . ." form with Pa. There is no duplication of services. Waiver continues to be the payer of last resort. Pa remains NFCE Waiver appropriate. SC document on SC reviewed Provider Choice, 10 item ISP checklist including rights and responsibilities and right to appeal. SC reviewed Participant Information Packet including: Your rights as a Participant, Your responsibilities as Participant, Participant choice, Applying for HCBS programs, Role of the Service Coordinator, Participant Complaints, How can I find other resources in my Community?, Medicaid (MA) Fraud and Abuse, Who do I contact If…, Abuse, neglect and exploitation, Self -directed services, and Your Appeal and Fair Hearing Rights. The following forms were reviewed and signed: ISP signature page, Provider Choice Form, Voter Registration Opportunity Preference Form and Authorization for Use and Disclosure

On the issue of timeliness, the PA IEB Representative RH testified that the Appellant was issued a notice on July 20, 2017, again on August 16, 2017 based on the Appellant’s request, and then again on September 13, 2017, based upon the Appellant’s request. The PA IEB’s position is that the appeal is untimely filed as the notice was issued three times before receiving the appeal on September 25, 2017.