Students will complete the following scenario as an essay.

As you are completing your audits you observe Mary Johnson’s chart and notice the following:

Mary Johnson saw Dr. Nichols today for a well-woman exam. Total charges are $185.00. Mary has two insurance companies:

Primary Insurance

Secondary Insurance

BCBS

Cigna Health Care

Copay: $25.00

Deductible: $200.00 (already met)

100% benefit after copay

80% benefit after deductible

Allowed amount: $150.00

Allowed amount: $125.00

Both claims were submitted at the same time in error.

Money collected from the patient: $0.00

1. Complete the following questions providing rationales for your responses:
   1. How much money did Dr. Nichols receive?
   2. How much should BCBS have paid?
   3. How much should Cigna have paid?
   4. How much is this claim overpaid?
   5. Who overpaid on this claim?
   6. What would be your next steps?
2. Address how this situation might be avoided in the future: be specific and provide steps.
3. The well-woman exam showed this patient due to family history of cancer would benefit from BRCA genetic testing and both insurance companies denied this claim. Format a letter of appeal or BRCA testing.

This assignment is completed as an APA style paper, and should be at least 2-3 pages in length. Demonstrate your business knowledge and professional ethics in your response.

Assignment Expectations:  

• Length:
  • answers must thoroughly address each question in a clear, concise manner; complete answers will likely take 2-3 pages
• Structure:
  • Title and reference page required
  • address each question in a numbered list
• References:
  • References required to be cited if used

reply 1

The term “negotiate” implies conferring with another to reach a compromise. Conflict exists if health professionals blindly advise patients, expecting them to follow the recommendations without understanding patients’ feelings or identifying barriers to patient adherence. Negotiation identifies areas of agreement and disagreement and provides a forum for discussion of solutions. (Falvo, 2011). Patient education is one of the important roles of nursing. Patient teaching can be effective only if patient understand and agrees to follow the instruction. Negotiation is a way to work collaboratively with the patient to establish mutually acceptable goals and problem solve to assist patients’ ability to reach them. Negotiation helps to create effective teaching learning environment. Back in the day, the doctor was considered the last word when it came to a patient’s decision making. Today, physicians share the decision-making with their patients because patients have other things going on in their life that they must include in their healthcare decisions such as careers, families, time constraints and other realities. They need to work with physicians to establish effective, individualized treatments that works for the patient and the provider. The term negotiation, when applied to health care, indicates that a back and forth discussion is occurring where proposed treatment options are presented by the health care professional, considered by the patient, and either accepted, rejected, or altered to fit the patient’s needs (Falvo, 2011). By negotiating with patients, physicians and patients can reach a healthy decision for both parties.

In my practice with the increase of social media on the public’s decisions on healthcare matters, it is important to talk to the patient about their fears and reasons why they want or do not want. By educating them and providing them with evidence-based practice but still letting them make the decision will make them feel more included in the decision process.

Falvo, D. R. (2011). Effective patient education: A guide to increased adherence. (4th ed.). Jones & Bartlett Publishers. Retrieved from: https://viewer.gcu.edu/RQBKXW

reply2

According to the reading “negotiate implies conferring with another to reach compromise” (Falvo, 2011). The reading also points out there are different levels of negotiation by providers. Some (providers) may feel that negotiation interferes with what they consider to be the major goal of patient teaching: to offer information that will help patients improve or maintain health (Falvo, 2011).

Negotiation is part of building a partnership between the provider and patient. Negotiation is a way to work collaboratively with the patient to establish mutual goals and identify problems. Identifying the problems will allow patient’s the ability to reach the goals (Falvo, 2011). Providers also can find areas in the treatment plan the patient may not agree with, this important because this correlates with compliance as well as expectations of outcomes.

I would say that negotiation is a tool that can better or assist in relationships/partnerships between providers and patients. When providers are willing to accept that patients as partners, listen to their side of things and negotiate or meet somewhere in between there is responsibility on both parties. Patients must be honest with providers however and providers must be more flexible. Although the provider is expected to communicate and educate the patient is also responsible for their actions such as following the treatment plan.

An example would be a patient sees a physician the physician says the patient has high cholesterol. Educates on what this finding means, the risks, and suggests medication to correct the problem. The patient voices that she doesn’t want to take medication for the high cholesterol. The physician than explains alternatives to decrease the cholesterol. The patient chooses a non-medication route, the physician then based off this tells the patient they have one month to decrease their cholesterol. The patient and provider agree on the number expected for cholesterol in one month. The physician suggests that the patient decreases trans fats in their diet, adds fiber, adds exercise, and completes smoking cessation (Thorpe, 2017). If the patient goes back and there is not a change the physician tells the patient the medication will need to be started. The patient agrees. The key is now that the patient must be honest whether or not they held them self-accountable and made changes or not when following up. The patient also must express any concerns or difficulties they face with the provider. If the cholesterol is not lower the patient must also follow through on their part of the negotiation.

Critical thinking: Negotiation works in healthcare like it would in any type of relationship. If you tell someone everything is my way and I don’t care about what you think. Most likely that person isn’t going to do what you ask compared to if you said ok, I could see your point can we find a common ground to a solution we agree on. This type of relationship is beneficial for the provider and patient to increase better patient outcomes. Another benefit is the responsibility on the patient as well as the provider. The roles of patient and provider have changed and allows many different levels of acceptance as well as ways to in cooperate better health and patient centered care.

References:

Falvo, D.R. (2011) Effective patient education: A guide to increased adherence. Retrieved from http://gcumedia.com/digital-resources/jonesandbartlett/2010/effective-patient-education_-a-guide-to-increased-adherence_ebook_4e.php

Thorpe, M. (2017). 10 ways to naturally lower cholesterol. Retrieved from https://www.healthline.com/nutrition/how-to-lower-cholesterol