Questions On Health Insurance Coverage

856 WordsJul 21, 20154 Pages
Another scenario: Mr. Smith has straight Medicare insurance, he is eligible for 100 days of in-patient rehabilitation in hospital or skilled nursing home after his hip replacement. Giving him enough time to recover. Thus, individual’s recovery with managed care is impacted by the limited days allowed by the insurance personnel. That affects the recovery and also the safety of the person after discharge from the nursing home. Eventually affecting the facility’s reputation and also limiting financial reimbursement to the facility. Let’s consider Medicare insurance coverage for an individual. In the case of Mr. Smith, considering he has Medicare coverage, he will be allowed 100 days of Inpatient rehab. In these 100 days, he will receive…show more content…
Mr. Smith did well with therapy during the 1st week of rehab and was in the ultra/high window. But unfortunately he suffered from urinary tract infection at the end of second week and could participate to qualify for the ultra/high. He was short of 10 minutes at the end of second week. In this case, facility will get the reimbursement for high level. Which could be half the cost of Ultra high. In order to keep an individual for ongoing rehab, the person’s participation needs to be shown. This is shown by the number of minutes he/she participates in therapy. Sometimes, because of the acuity of illness, the person is not able to perform well, resulting in limited participation and number of minutes for therapy. When insurance sees this, they disqualify for rehabilitation. This puts an individual at risk. In order to avoid this, the organization plans to get more minutes by engaging individuals in therapy for minutes needed and to show individual compliance, despite of person’s physical capability that day. BUSINESS PROFITS VS CORE VALUES AND ETHICS: The current health care environment has created the potential for ethical issues
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