Jennifer E. Kisner
The following research is being submitted on October 25, 2012, for Carol Taylor’s
Medical Law and Ethics class.
Medicare is available for persons age 65 or over, disabled persons that are entitled to Social Security or Railroad Retirement, and those with end-stage renal disease. The Medicare patient must pay a deductible fee and the difference is covered by Medicare. There is a cutoff of reimbursement for care beyond 60 days. According to the new rules enacted by the Department of Health and Human Services in August 1997, a patient with Medicare HMO may appeal the decision when there are denials for treatment.
The Diagnostic Related Groups (DRGs) is a database used in the Medicare instituted or hospital payment systems. The patients are categorized by diagnoses and treatments that are used to identify methods for reimbursement. Under this group system, the hospitals/health centers receive a set sum amount by the insurance company, regardless the number of days for treatment. This kind of system has caused patients to be discharged early before treatment is completed because of the extra costs that are not covered when the insurance runs out.
The Medicaid federal program was implemented by the individual states to provide financial assistance to states to insure certain categories of poor and indigent persons. Medicaid does not cover all medical conditions. Each individual state enacts their own legislation to manage how the funds should be spent. Some states use a daily rate payment system and other states use the prospective payment system which the payment amount is known in advance.
Many health care professionals find it difficult to provide any decent minimum standard of care to everyone in the managed care system. Usually patient’s best interests are sacrificed due directly to company profit. The current perception of federal managed care is the sacrifice of quality care and costs. Using this...