Regulatory environment in Healthcare PDF
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Added on 2021-10-30
Regulatory environment in Healthcare PDF
Added on 2021-10-30
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Running head: REGULATORY ENVIRONMENT IN HEALTHCARE 1
Regulatory Environment in Healthcare
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Regulatory Environment in Healthcare
Name:
Academic Institution:
Date:
REGULATORY ENVIRONMENT IN HEALTHCARE 2
The procedural remedies that patients would likely have under private insurance and
Medicare or Medicaid include the right to appeal on the decision of the HMO. In the situation
where the plan denies coverage for the patient, the patient gets a drafted notice of the benefit
determination which again contains Coverage Decisions and Dispute Health Care Service
resolutions from the HMO as required to be done. In this notice, the plans reasons are well
explained for the decision taken and explanation of the next course of actions that the patient
should decide if he or she wishes to launch an Appeal (Klink, 2011). The Appeal is only done in
writing, and the member must comply within 180 calendar days for the same date the notice is
given out.
Similarly, the member is expected to request an Urgent Care Claim as part of the
procedural remedy. The reason for filing urgent care claim is to receive medical care or
treatment, and it comes when there is a delay in providing care to the patient who is a member.
For quick reviews, it is always filed by doctors on behalf of the patient for faster processing than
normal time allowed, since the life of the patient could be in danger or at risk if the claim is not
decided faster (Grossman, 2016). Under normal circumstances, the care is always reviewed
within 72 hours by personnel who are not involved in preparing the benefit determinations.
As part of the procedural remedy, the member may also request an independent medical
review for the services recommended or carried out by a non-participating health care service
provider. Besides, there is another alternative for seeking an independent medical review which
is only done after the completion of the form that is received from the HMO and take it to the
Department of Managed Health Care. After the department confirms its receipt, it is reviewed,
and the person decides on the Member’s request if he or she meets the criterion for independent
review (Palley, 2011). If it is confirmed, the Appeal of the member will be taken to the
The procedural remedies that patients would likely have under private insurance and
Medicare or Medicaid include the right to appeal on the decision of the HMO. In the situation
where the plan denies coverage for the patient, the patient gets a drafted notice of the benefit
determination which again contains Coverage Decisions and Dispute Health Care Service
resolutions from the HMO as required to be done. In this notice, the plans reasons are well
explained for the decision taken and explanation of the next course of actions that the patient
should decide if he or she wishes to launch an Appeal (Klink, 2011). The Appeal is only done in
writing, and the member must comply within 180 calendar days for the same date the notice is
given out.
Similarly, the member is expected to request an Urgent Care Claim as part of the
procedural remedy. The reason for filing urgent care claim is to receive medical care or
treatment, and it comes when there is a delay in providing care to the patient who is a member.
For quick reviews, it is always filed by doctors on behalf of the patient for faster processing than
normal time allowed, since the life of the patient could be in danger or at risk if the claim is not
decided faster (Grossman, 2016). Under normal circumstances, the care is always reviewed
within 72 hours by personnel who are not involved in preparing the benefit determinations.
As part of the procedural remedy, the member may also request an independent medical
review for the services recommended or carried out by a non-participating health care service
provider. Besides, there is another alternative for seeking an independent medical review which
is only done after the completion of the form that is received from the HMO and take it to the
Department of Managed Health Care. After the department confirms its receipt, it is reviewed,
and the person decides on the Member’s request if he or she meets the criterion for independent
review (Palley, 2011). If it is confirmed, the Appeal of the member will be taken to the
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