Healthcare

The United States of America is the only Wealthy, Industrialized, and Developed nation that does not have a universal healthcare system. The country uses a mix of private, employer-provided plans, and government programs like Medicare and Medicaid to over different populations. This leaves Millions uninsured or underinsured.

High costs

The U.S. spends more on healthcare per capita and as a percentage of its GDP than other developed nations, yet it does not achieve better overall health outcomes.

Consequences

The lack of universal coverage contributes to medical debt and can lead people to delay or forgo needed medical care.

Treatment Options

Inpatient

“Acute Care” are immediate service that Require Hospitalization. Commonly determined by a Physician in the Emergency Department.

Admitted as “INPATIENT” means that the individual is expected to spend 3 midnights in the hospital.
An “Admissions Department” representative will often show up with paperwork, asking for a signature.
The Legally Binding paperwork contains information that the representative does not explain in full. Know what you’re signing by familiarizing yourself with an Admission example seen Here.
Any event that requires visiting the Emergency Room is stressful. Most individuals cannot comprehend legal terminology under these circumstances. It is better to delay signing anything until a better time allows.
Important Note: As Hospitals are a business, a person may be assigned a hospital bed and admitted and classified as “OBSERVATION”. This is a completely different status, for which the patient is billed differently. These are services that could be performed outside of the Hospital. More information is provided in the following category.

Outpatient

Outpatient- Services that do not require to be Hospitalized

Accreditation and billing for each category varies. Remember to use the lowest form necessary as billing reflects level of acuity.

Primary Care Provider

Walk-in Clinic

Urgent Care Clinic

Hospital (Click Here to view example of Outpatient Notice)

Post Acute-Care

Hospitals are considered as trusted safety and refuge locations.
This allows Hospital Staff to facilitate transitional planning after hospitalization, which may not be otherwise available.
Placement options: Assisted Living Facilities (does not accept insurance), Skilled Nursing Facilities (SNFs), Nursing Homes, Inpatient Rehab Facilities (IRF), etc.

Role of Insurance

To help offset the costs of medical expenses to patients for routine and emergency medical services.

Post Acute-Care

Private or Employer-Provided

PPO (Preferred Provider Organization)- a managed healthcare plan where the participants are free to utilize the services of any provider who is within their network, at a reduced rate for services provided. They are also able to still seek care from providers outside of their network and be covered under their insurance, but rates will not be reduced like the in-network options. This type of plan does come with higher co-pays, deductibles, and premiums; however, this is the tradeoff for the increased flexibility in coverage/provider options.
HMO (Health Maintenance Organization)- limits coverage to entities that are in-network, except for the in the case of emergencies. This type of plan does place more restrictions on provider options; however, it does offer patients lower premiums and out-of-pocket costs.

Medicare

Part A – Covers Hospitalization and Hospice. Limited to 90 days during benefit period. Costs $1600 for first day.
- Days 61-90 are about $400/day.
- Days 91-150 are Lifetime Reserve Days and cost around $800/day.
- SNF Days 1-20 are covered in full
- SNF Days 21-100 is around $200 per day
Part B – Outpatient Services (Supplemental Medical Insurance) and DME.
Part C – Prescription Drug Program.
Part D – Medicare Advantage, and Medigap are sold through private insurance carrier, not the federal government. The advertisements and incentives for these options can be misleading for individuals, so it is best to consult with SHIPs (State health insurance assistance program), who offer free personalized insurance counseling and ensure patients’ rights are protected under Medicare.
- Healthgrades.com Solucient, THCIC, M

Frequently Asked Questions

Why do I get so many bills? Who are they coming from? What Can I do about it?

What can I do if Insurance Denies my Claim?

If an insurance claim gets denied (ex. Medications, procedures, imaging), the patient can request that the provider obtain a peer-to-peer review if one has not been initiated, to see if this can facilitate the approval of the claim.

If I don’t sign any papers, can it affect me being treated?

Due to the EMTALA (Emergency Medical Treatment and Labor Act), hospitals who participate in Medicare cannot deny emergency services to anyone who requests them during an emergency, regardless of insurance status or ability to pay.

How do Hospitals Make money (Inpatient)?

Reimbursements for services that are provided through insurance.

Recent shift from quality emphasis to “Value-Based” Healthcare”
Focus is on decreasing length of stays, Quantity over Quality