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For individuals who have insurance the cost and coverage varies greatly. There is variability on what care is covered, having to get pre-approval, who can provide the care, and where it can be delivered. Even with insurance individuals can have problems with medical bills and accrued medical debt, obtaining preventive health care, and problems with managing chronic medical and mental health conditions.
1. Does having insurance guarantee good health care?
2. What does it mean to be under-insured? Explain why this population has no or limited access to health care.
3. For the health care provider what are some of the problems in having to interact and bill multiple health insuranceplans- cost to the practice, how care is delivered?
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Having health insurance is not a guarantee for good health. It is mainly because a patient’s ability to pay for health care (irrespective of cover) is not a guarantee for quality health services. According to the IOM, quality health is safe, effective, timely, patient-centered, equitable, and efficient (Allen-Duck, Robinson & Stewart, 2017). Insurance allows physicians to refer patients within their institution and out-of-network for specialized services. Out-of-network services may be more costly and referrals within the facility may hinder the patient from the required quality services. It is not consistent with the definition of quality care.
Underinsurance is a state where a patient has insurance coverage but the insurance doesn't offer coverage for some medical expenses. An under-insured patient may not get the required health care due to the high out-of-pocket costs involved (Fang et al., 2016). Consequently, they are less likely to have poor health due to the inability to access the needed medical help.
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Filling multiple plans is a frustrating experience for the health care organization. It requires that health providers fill enormous claims which often require special automated tools. Inadequate skills or automation may necessitate health providers to fill each claim individually. Doing so impacts the efficiency of the health provider and, eventually, on clinical workflow (Saripalli, Triumala & Chimmad, 2017). Additionally, failure to include all patient information may result in delays or cancellation of claims. All the situations harm the health provider and service delivery.
Allen‐Duck, A., Robinson, J. C., & Stewart, M. W. (2017, October). Healthcare quality: a concept analysis. In a nursing forum (Vol. 52, No. 4, pp. 377-386). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640472/
Fang, J., Zhao, G., Wang, G., Ayala, C., & Loustalot, F. (2016). Insurance status among adults with hypertension—the impact of underinsurance. Journal of the American Heart Association, 5(12), e004313.
Saripalli, P., Tirumala, V., & Chimmad, A. (2017, October). Assessment of healthcare claims rejection risk using machine learning. In 2017 IEEE 19th International Conference on e-Health Networking, Applications and Services (Healthcom) (pp. 1-6). IEEE.
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