Xa Umshuwalense wezeMpilo wenqaba ukufihla i-ER
Ukuba uthe wagqithisa umnwe wakho etafileni wabona, kucacile ukuba igumbi lexakeka kufuneka libe yindawo yakho yokuma. Kodwa akuzona zonke iimeko eziphuthumayo ezicacileyo.
Amagumbi angxamisekileyo yiindawo ezibiza kakhulu ukufumana unyango lwezempilo, ngoko-ke imeko ezingezoxakeka, abo bango-inshuwalense bafuna amalungu abo ukuba asebenzise ezinye iindawo eziphantsi kweendleko, kubandakanya amaziko okunakekelwa ngokukhawuleza okanye i-ofisi yokunakekela abantwana abasesikweni.
Xa izigulane zisebenzisa izakhiwo ezingezizo ii-ER, ixabiso elincinci kwi-insurer, kwaye liguqulela kwixabiso eliphantsi lokunakekelwa kwempilo-kunye neepresimesi ezisezantsi-wonke umntu. Kodwa kwimeko yesimo esongela ubomi okanye nesigxina, igumbi lesiganeko liza kuba yindawo efanelekileyo efanelekileyo ukulungiselela ukujongana neemeko ezithile.
Kwaye i-conundrum kukuba abantu abaninzi abaqeqeshelwa ngamayeza angxamisekileyo, ngoko ke ukuba unokungathandabuzeki ngokunyaniseka kwimeko yezokwelapha, ukuphosa kwicala lokulumkisa (oko kukuthi, ukuya kwinqanaba lezongxamiseko) ngokubanzi kubonakala ngathi isisombululo esinengqiqo.
I-Anthem idala ukuphikisana neNew ER Imithetho
Ngona nxalenye enkulu, i-inshorensi ihlawula ezo zihambo kwindlu yokuphucula. Kodwa i-Anthem ibangele ukungqubuzana nemithetho emitsha eGeorgia, e-Indiana, e-Missouri naseKentucky (ngo-1 Julayi 1, 2017 efanelekileyo), eguqulela iindleko ze-ER ukuvakashela isigulane ukuba ukuhlaziywa kwamabango kuthatha ukuba imeko ayiyonto engxamisekileyo emva bonke.
Isigulane esichazwe yiVox siye ekamelweni eliphuthumayo eKentucky ngeentlungu zesisu nangomkhuhlane. Unina, owayengumongikazi wangaphambili, wamcebisa ukuba ahambe kwigumbi lokuxakeka, njengoko iimpawu zakhe zidibene ne- appendicitis , ebonwa njengongxamiseko lwezonyango. Kodwa kwavela ukuba wayenama-cysts e-ovarian endaweni ethile, into eyayibhalwe kuphela emva kokunyangwa kwonyango kwakunikeziwe kwi-ER.
I-Anthem yamthumelela i-bill ye-$ 12,000 ngaphezulu, ithi ibango lakhe liphikisiwe ngenxa yokuba wayesebenzisa igumbi lexakeka ngokunyamekela ngononophelo olungxamisekileyo. Isigulane sathintela, sichaza ukuba wayenalo indlela yokukwazi ukuba intlungu yakhe yayingekho yongxamiseko kwaze kwafika oogqirha be-ER. Ekugqibeleni, emva kwesibini isibheno sakhe (kwaye emva kokuba isigulane sichaze ibali lakhe ngeVox), i-Anthem ikhokhe i-bill.
Iimvavanyo ze-ER zivame ukubangela iintloko
Imithetho emitsha ye-Anthem isenokuchaphazela ezinye izigulane ezininzi kuzo zonke ezine. Kodwa iindleko zezonyango ezathusayo ezibangelwa luhambo oluya kwi-ER azintsha.
Amanye amazwe anemithetho efanayo ye-Medicaid ababhaliweyo, kunye neefayili eziphezulu zokusetyenziswa okungxamisekileyo kwegumbi lesiganeko (nangona ngokuhambisana neMithetho yeMedicaid, iikopi zisaxhomekeka xa zifaniswa neendleko zenkathalo enikeziwe kwi-ER).
Kwaye abantu abangazifumani ngokungazenzisiyo kwi-ER abangaphandle kwintanethi yabo yesicwangciso senkonzo yomshuwalense banokuphelisa kunye neendleko zezonyango ezinkulu, nangona i-ACA idinga iiplani zezempilo ezingenakulinganisekanga ukuba zikhuphe ukunyamekela kwangxamisekileyo ngaphandle kwenethiwekhi njengokuba umnatha.
Lezo zibango sele zihlolisiswe, kunye nabaqhankqalazi abahlola ngokuphindwe kabini ukuqinisekisa ukuba unonophelo lwangxamisekileyo ngaphambi kokuhlawula i-B-out-of-network.
Kwaye nangona i-inshurensi ihlawula ibango ngokungathi i-in-network, i-out-of-network ER ayinyanzelwanga ukuba yamkele intlawulo yomshuwalense njengentlawulo epheleleyo, ekubeni i-ER ayinaso isivumelwano kunye ne-insurer, kwaye inokulinganisela ibhalwa isigulane kwisabelo sebhili-mali esisele emva kokuba i-inshurensi ihlawule. Ukuba bekuyi-in-network indawo, i-ER kufuneka ibhale inxalenye yesikhokhelo, phantsi kwemiqathango yesivumelwano kunye nomshuwalense. Kodwa akukho mfuneko enjalo kwiindawo ezingaphandle kwee-network.
Ubume bokunakekelwa ngxakeko kwenza kube nzima kwizigulana ukuzithoba ngee-inshubhe ze-inshorensi eziya kuba zichanekileyo.
Kwiimeko ezingezoxakeka, abantu baqhagamshelana neenkampani zabo ze-inshorensi ukuba babuze malunga nokugunyazwa kwangaphambili okanye bahlole ngogqirha oyintloko okanye unesi-hotline ukuze ubone ukuba unyanzeliswa njani. Kodwa kwimeko engxamisekileyo-okanye into ebonakalayo yimeko engxamisekileyo, ukusuka kwimeko yesigulane-ezo zinto zinganakwa.
Kwaye inxalenye enkulu, yindlela emele ukuba ngayo. Ukuba umlingane wakho unesifo, ungazixhalabele ngokubiza inkampani yakho yomshuwalense-kufuneka ubiza 911 okanye ufike kwi-ER ngokukhawuleza.
Kodwa xa abathengi beva ibali malunga nabaqhankqalazi abaphika ii-ER zebhilidi ngenxa yokuba umshwalense kamva wambona imeko engeyona yongxamiseko, kuyacaca ukuba iyakhathazeka. Isigulane kwisiqendu seVox sathi emva kokuba amava ayenayo kunye ne-ER bill kunye ne-Anthem ibanga ukukhanyela, kwixesha elizayo "uya kuzinyameko eziphambili, kwaye kuya kufuneka amphoqe [ukuba] aye kwi-ambulensi ukuya kwigumbi loxakeka. "
Qonda iPolisi Yakho-Ngaphambi kokuba Yiphumelele
Xa uyazi ngakumbi malunga nendlela yakho ye-inshorensi yezempilo isebenza ngayo, bhetele ulungele ukuba uya kuba ngeemeko xa ugqiba ukufuna ukusebenzisa i-coverage yakho. Ngoko, inyathelo lokuqala kukufunda ngokucophelela kwaye uqonde umgaqo-nkqubo wakho. Abantu bavame ukuwufaka kwi-drawer baze bayikhohlwe malunga nokude bafune ukuyisebenzisa, kodwa akukho xesha lokuba kwimeko engxamisekileyo. Ngoko, ngexesha apho ungakhange ujongane nesidingo esisondeleyo sokunakekelwa kwezempilo, hlala phantsi nomgaqo-nkqubo kwaye qiniseka ukuba uyaqonda:
- Iindleko ezidityanisiweyo kunye ne- out-of-pocket kwisicwangciso sakho, kwaye nayiphina i- copay esetyenziswa kwi-ER ukutyelela (phawula ukuba ezinye iipolisi ziya kulukhupha i-copay ukuba ugqiba ukuba ungeniswe esibhedlele nge-ER, kwaye iifayili izakufaka isicelo yakho inokutshatyalaliswa-ezi zihlobo lwezinto ofuna ukuzenza ngaphambi kwexesha, ngoko kubiza inkampani yakho yomshuwalense kwaye ubuze imibuzo ukuba awuqinisekanga ukuba isicwangciso sakho sisebenza kanjani).
- Ingaba icebo lakho lijongene nokunyamekela kwenethiwekhi , kwaye ukuba kunjalo, nokuba kukho ikhefu kwiindleko zakho zokunakekelwa kwenethiwekhi ngaphandle. Ukongezelela, ukuba kukho i-ER engaphezulu kwendawo yakho, uya kufuna ukukhetha ukuba yeyiphi inethiwekhi yesicwangciso sakho kwaye awunjalo, kuba loo nto ayiyiyo into ofuna ukuxhalabisa ngayo kwiimeko ezingxamisekileyo.
- Ingaba isicwangciso sakho sinomgaqo oya kubangela ukukhanyela ibango ngokusetyenziswa okungxamisekileyo kwe-ER. Ukuba kunjalo, qhelanisa ne-insurer yakho inkcazo yexakeka ngokubhekiselele kwiimeko ezingxamisekileyo. Ukuba izikhokelo zingabonakali zicacile, biza umnini-mali wakho ukuba uxoxe ngale nto kunye nabo, ukuze ukwazi ukuqonda oko kulindeleke kuwe ngokwemiqathango yesibonelelo omele usebenzise kuzo kwiimeko ezahlukeneyo (i-Anthem ichaze izikhokelo kwileta abathumele kumalungu ngo-2017, xa imithetho yabo entsha eGeorgia, e-Indiana, eMissouri naseKentucky yaqalisa ukusebenza).
- Ziziphi iimfuno zakho ze-inshurensi zihambelana nokugunyazwa kwangaphambili kweenkqubo zonyango ezilandelayo ezivela kwi-ER.
Yintoni Okufanele Uyenze Ukuba Ufumana IYilwayo Engazange Yilindeleke?
Ukuba ufumana ibhilikithi enkulu kunokuba ilindele emva kokutyelela kwi-ER, fi kelela kwi-insurer yakho uze uqinisekise ukuba uyayiqonda yonke into malunga ne-bill. Ingaba ibhanti yebhanti ukusuka kwi-ER engaphandle kwenethiwekhi? Okanye ngaba ibango lokukhanyela ngenxa yokuba umgcini wakho womshuwalense ubona imeko yakho engeyona ingxamiseko? Ixesha langaphambili lihlala liqheleke ngakumbi, kodwa, ngelanga, imeko apho isigulane singaphantsi kwindlela yokufumana.
Ukuba ufumene ibhajethi yebhanki kwi-ER ngaphandle kwe-network (okt, i-insurer yakho ihlawule inxalenye yesibango, kodwa i-ER ikuhlawula yonke into, kwaye ingabhalisi nayiphi na inkunkuma ngoba akunayo isivumelwano kunye nomshuwalense wakho), kukho izinto ezimbalwa ofuna ukuzenza:
- Hlola kwisebe likarhulumente we-inshorensi ukuba ubone ukuba kukho imithetho yokukhusela abathengi okanye imimiselo kwimeko yakho ekujonganeni nokuhlawula imali kwiimeko ezixakekileyo. Akukho mithetho yomgaqo-nkqubo okhusela ukuhlawula ibhalansi kubanikezeli bee-out-of-network, kodwa abanye bathi baye bajongana nale mbambano .
- Ukuba akukho nto uhulumeni wakho angayenza, finyelela ngaphandle kwe-network ER ngqo kwaye ubone ukuba baya kuxoxisana nawe. Basenokuvuma ukufumana imali encinci njengentlawulo epheleleyo.
Ukuba ufumene isaziso sokuba ibango lakho liphikisiwe ngenxa yokuba i-insurer yakho inqume ukuba imeko yakho ayiyonto engxamisekileyo (kwaye ukholelwa ukuba ngokwenene, imeko yimeko engxamisekileyo okanye ubuncinane umntu oya kucinga ngayo imeko engxamisekileyo), unomdla ongakumbi ngokwemigaqo yezibheno:
- Ukuba isicwangciso sakho asizalwanga, i-ACA ikuqinisekisa ukuba unelungelo lokubhena inkqubo yangaphakathi, kwaye ukuba umgcini-mali unyanqaba ibango lakho, unokufumana ukuphononongwa kwangaphandle ngumntu wesithathu ozimeleyo (nantsi isishwankathelo sokubhena kwezibheno inkqubo yomsebenzi).
- Unokuqala ngokuqalisa inkqubo yesikhalazo sangaphakathi kunye ne-insurer yakho, kunye nokufikelela kwiSebe le-inshurensi yelizwe ukuze ubone ukuba banakho isikhokelo kuwe.
- Gcina umkhondo wento eyenzekayo ngexesha leenkqubo zokubhenela, kuquka amagama abantu othetha nabo kunye naluphi na unxibelelwano olufumanayo kwi-insurer yakho. Uyakufuna kwakhona ukugcina isibhedlele kwisiqhelo, njengoko kunokufuna ukuhambisa ulwazi olongezelelweyo kwinkampani yomshuwalense ukwenzela ukuba ubonise ukuba imeko yakho iqinisekisa ukuba uhambo oluya kwi-ER.
- Ukuba izibheno zangaphakathi nangaphandle zangaphumelelanga, uya kufuna ukujongana nesimo esibhedlele. Bangaba bazimisele ukunciphisa i-bill okanye bafake icebo lokuhlawulwa.
Ukuphikisana Kwimimiselo ye-ER
Iindaba ze-ER ezitsha zikhokelo ze-ER eGeorgia, e-Indiana, eMissouri naseKentucky zadibana nesikhalazo esivela kwizigulane kunye nabameli babathengi. I-American College of Physicians Emergency iqhutywe ngevidiyo eyenzelwe ukugqamisa iimpazamo kwinkqubo eyenza ukuba izigulane ziqonde oko kwaye akuyona ingxamiseko, xa ezinye iimeko zingenakuhlolwa ngaphandle kokuvavanya.
I-Anthem ithe indlela yabo yokusebenza isekelwe kulwimi esele lisezikontrakthi zabo, kwaye ukuba "isalathisi sokuziphatha" isetyenziswa rhoqo kodwa ngoku iyanyanzelwa (oko kukuthi, ukuba "umntu onobuqili" uya kuthathwa njengento engxamisekileyo, ngoko Ingxamisekile). Kodwa ngokucacileyo, oku kuhambelana nokuphikisana. Izigulane, abanikizi bezonyango kunye nabaxhasi babathengi banenkxalabo yokuba isenzo singasasazeka kuma-inshurensi amaninzi, eshiya izigulane zingenakucaluleka (ngexesha elingabalulekanga) malunga nokuba ufuna ukunyamekela kwi-ER, okubangelwa kwiziphumo zempilo ezihluphekayo. Kodwa i-Anthem, kwaye mhlawumbi amanye ama-inshurensi okumele alandele, ijolise ekuhlaziyweni kwiindleko zempilo-umsebenzi ophantse ngawo wonke umntu uyavuma, kodwa bambalwa abavumelana malunga nendlela yokufezekisa.
Kwaye nangona kubango ukungafuni ukusetyenziswa kwe-ER ngokungafunekiyo ngokukhawulezileyo kukudala ukudideka kunye nokukhathazeka, umba wezindleko zonyango olumangalisa emva kokutyelela i-ER ibe yinkathazo eqhubekayo eyandulela inkqubo entsha ye-Anthem. Amaqela ngabanye asebenze ukujongana nombandela kwezinye iimeko, kodwa ihlala ingxaki kwiindawo ezininzi zelizwe.
Nangona izisombululo zibonakala zibonakala xa zijongwa ngumbono okanye ummeli wabathengi, kunzima ukufumana bonke abachaphazelekayo. Ngeli xesha, abathengi kufuneka baqonde kangangoko banokukwazi malunga nokusebenza kwazo kunye nokuba zeziphi amalungelo abo ezibheno xa zifumana i-bill engalindelekanga emva kokutyelela kwi-ER.
> Imithombo:
> Iikholeji yaseMerika yaseMantla. Amagqirha angxamisekileyo aveza iPolisi yeNkcazo yoNcedo oluPhatha kakubi kunye neVidiyo entsha. NgoJanuwari 17, 2018.
> Amasebe e-Medicare neeNkonzo zeMedicaid. Amabango aPhakathi kunye neziBheno kunye nokuPhononongwa koPhulo lwangaphandle. Ngo-Apreli 12, 2017.
> Umbutho kaZwelonke weeKomishinari ze-Intshu, Imephu: Amazwe kunye neziGwetha.
> Pollitz, uKaren. Kaiser Family Foundation. Bills Medical Bills. Matshi 17, 2016.