Ingaba inkampani yakho yinshorensi yempilo ikunike umphathi wecala? Ngaba uyabonwa ngumphathi wecala kwisibhedlele okanye kwinkampani yezempilo yasekhaya? Ngaba ungumongikazi ofuna ukuba ngumphathi wecala? Andiqinisekanga ukuba yintoni na umphathi wecala, ukuba kutheni ufuna enye, okanye yintoni oya kuyenza xa waba ngumphathi wecala? Nakhu okufuneka ukwazi.
Ulawulo lweMeko lunokuthi lithetha izinto ezahlukeneyo kwiindawo ezahlukeneyo
Okokuqala, kufuneka ukwazi ukuba yintoni umphathi wecala encike kwisimo apho asebenza khona.
Umzekelo, umphathi wecala osebenza kwinkampani yempilo yonyango uza kunika iinkonzo ezahlukeneyo kunommeli wecala kwinkampani yomshuwalense wezempilo, inkampani yomshuwalense yempesheni yempesheni okanye isibhedlele.
Nangona kunjalo, kukho izinto ezithile ezihambelanayo kuzo zonke iindima zolawulo. Ngaloo ndlela, abaphathi bamatyala bavavanya iimfuno zesigulane kunye nezibonelelo ezifumanekayo. Abaphathi bamatyala bazama ukufumana indlela efanelekileyo, eyona ndlela isebenzayo, ebonakalayo yokwenene yokuhlangabezana neemfuno zesigulane kunye nezibonelelo ezikhoyo.
Ngokukodwa kwiimeko zonyango ezingapheliyo, ezinzulu, ukulawulwa kwimeko kungabangela iziphumo ezingcono kwizigulane, ukuthobela ukuthotyelwa kweengcebiso zonyango kunye nokuziphatha kakuhle komonde-nangona kukho imida kwiimpembelelo zokulawulwa kwimeko. Nantsi imimiselo yoluphi umphathi wecala akwenzayo kwizicwangciso ezahlukeneyo.
UMphathi wezeMpilo
Umphathi wecala lesibhedlele ngokuqhelekileyo ungumongikazi owenza ukuhlaziywa kokusetyenziswa kokubili kunye nokucoca .
Ukuhlaziywa kokusetyenziswa kuquka ukuqiniseka ukuba isigulane sinokunyamekela okuyimfuneko yonyango kwaye siyifumana kwisimo esifanelekileyo. Ukucandwa komsebenzi yinkqubo yokuqikelela izigulane eziqhubekayo nezidingo zonyango emva kwesibhedlele kwaye zibeka isicwangciso sokuhlangabezana nezidingo. Abaphathi bezezibhedlele zezibhedlele baziintloko xa beququzelela iimfuno zononophelo ngononophelo kwixesha kunye nababoneleli .
Ngokomzekelo, ngumphathi wecala lokubhedlele esibhedlele eliqinisekisa ukuba inkampani ye-inshorensi yempilo iyayiqonda into eyenzekayo ngexesha lokubeleliswa kwezigulane. Uyaqinisekisa ukuba i-inshurensi inolwazi olufunekayo ukuvuma ukuhlawulwa kwesibhedlele kwaye isebenza ukukhusela ukungabikho kwebango le-inshorensi. Uthetha nomphathi weefayili yempilo nganye imihla okanye yonke imihla embalwa.
Nguye olungiselela isigulane ukuba atyelele ekhaya evela kumhlengikazi ovakasayo emva kokukhutshwa esibhedlele, okanye ukufumana ukulungiswa kwesifo esibuhlungu kwisibonelelo sokulungisa izifo. Nguye osinceda isigulane ukhethe inkampani yempilo yasemakhaya okanye isixhobo sokuvuselela izigulane esise-intanethi kunye nomshuwalense wakhe kwaye simamkele njengesigulane.
Ukongezelela, umphathi wecala lesibhedlele unokuthi axoxisane ngezibonelelo zokufikelela phakathi kwe-insurer, umniki kunye nesigulane. Nasi umzekelo: Mhlawumbi isigulane esinokutheleleka kwethambo esingapheliyo sempilweni ngokwaneleyo ukuba siye ekhaya esibhedlele kwaye sifumane i-IV antibiotics ekhaya kwiiveki ezintathu ezizayo. Nangona kunjalo, umgaqo-nkqubo we-inshorensi yempilo awugubungeli iziyobisi ze-IV okanye izixhobo ezinjenge-IV kunye nezipompo ukuba isiguli sifune ukufumana iziyobisi ekhaya.
I-home pharmacy yekhaya ifuna isigulane ukuba ihlawule i-$ 5,000 ephaketheni lakhe kwisilwanyana kunye nezixhobo.
Umphathi wecala unokunxibelelana kunye ne-home IV pharmacy, inkampani yokunakekelwa kwezempilo yasekhaya, i-insurance insurer kunye nesigulane. Mhlawumbi ufumana isigulane ukuba avume ukuhlawula i-$ 1,000 engabizi kwiindleko zezilwanyana kunye nezixhobo ukwenzela ukuba angabikho esibhedlele ezinye iiveki ezintathu.
Ufumana kwakhona i-home pharmacy ye-IV ukunciphisa iindleko zezixhobo kunye nezixhobo nge-$ 1,000. Ufumana inkampani yokunakekelwa kwempilo yasemakhaya ukuba avume ukuthabatha ithebhu ye-IV ukumnika amaphampu ngamanani ama-$ 500.
Ufumana inkampani ye-inshurensi yezempilo ukuba avume ukuhlawula ikhemistri i-$ 2,500 eyiseleyo nangona ayifanele ukuba ayiyiyo inzuzo kumgaqo-mgulane.
Umshurensi uzimisele ukuhlawula i-$ 2,500 yee-$ 500 ukuze kungabi nakusasaqhubeka nokuhlawula isibhedlele ngezibonelelo zonyango. Ikhamphani yezempilo yasekhaya ikulungele ukuhlawula i-$ 500 kwimpompo kuba ukuba ayithethi, isigulane asiyi kuza ekhaya kwaye ayiyi kufuna nayiphi na inkonzo yononophelo yononophelo lwezempilo ekhaya. I-pharmacy ikulungele ukunciphisa ixabiso leziyobisi kunye nezixhobo nge-$ 1,000 ngoba ukwenza inzuzo encinci kungcono kunokuba kungabi nanye imali xa isiguli singakhutshwa.
Umphathi wezeMpilo weKhaya leMpilo
Umphathi wecala lononophelo lwezempilo ekhaya uyahluka kumphathi weze-esibhedlele kwisibhedlele apho edla ngokubonelela ngononophelo lwezigulane. Ukongezelela, udibanisa iinkonzo zamanye amalungu eqela lokunakekelwa kwezempilo kunye nabanonophelo, abonisana nenkampani ye-inshorensi yezempilo, ethetha nodokotela wegulane, kwaye uyaphatha abanye abahlengikazi abavakatyelayo okanye ii-aids zezempilo zekhaya ezibonelela ngononophelo.
Ngegalelo esuka kwisigulane kunye nosapho, umphathi wecala lononophelo lwempilo uhlakulela isicwangciso sengqondo sokunyamekela kwaye uyinike ugqirha wesigulane ukufumana imvume yokugqibela. Ulungelelanisa ukuphunyezwa kwesi sicwangciso kunye nesigulane, ababoneleli ngeenkonzo eziyimfuneko, kunye nokucwangcisa isicwangciso xa sidinga.
Umphathi weeNkampani ze-Inshurensi yezempilo
Umphathi wecandelo le-inshorensi yempilo ufumana ulwazi kubaphathi bee-hospital cases, iinkampani zempilo zonyango, iiofisi zonyango, abasebenzi bezentlalo kunye nabanye ababonelela ngempilo. Ngokuxhomekeke kwi-insurer kunye nendawo, unokusasazela isigulane esibhedlele.
Injongo yakhe kukuqinisekisa ukuba isiguli siyifumana unyango oluyimfuneko, ukunyamekelwa kwekhwalithi, kunye nokunyamekelwa kweenkonzo ngokufanelekileyo nangokwezoqoqosho njengoko kunokwenzeka. Ukulindela iimfuno zonyango lwempilo yengomso kwaye uzama ukubeka iindlela zokuhlangabezana nezidingo ngendlela efanelekileyo.
Kwezinye iinkampani ze-inshorensi yezempilo, unokunciphisa ububanzi bomsebenzi kwizigulane ezineenkqubo ezithile zesifo esingapheliyo. Ngokomzekelo, ukuba usebenza kuphela nezigulane ze- rheumatoid arthritis , ungobuchule bokuququzelela ukunakekelwa kwezilwanyana ze-RA kwaye unokulindela ukunyamekela kwabo kunye nokubeka ngokufanelekileyo iindlela zokuhlangabezana nezidingo. Unokunqumla kwi-tape ebomvu kwaye unokukwazi ukufikelela ngaphaya kweenzuzo ezixhamlekileyo ze-inshorensi yempilo kwaye uvume izinto okanye iinkonzo ezingenakugqitywa ngumgaqo-nkqubo we-inshorensi yempilo kodwa oko kuya kwenza ukuba ukunakekelwa kuhanjiswe ngokufanelekileyo nangokugcina imali ngokukhawuleza. Usebenza ukuhlangabezana neemfuno zesigulane ngelixa ugcina iliso kwizantsi kunye nexesha elide.
Ngubani olawula iimeko?
Ukulawulwa kwetyala ngokuqhelekileyo kwenziwa ngabahlengikazi, kodwa kungekho rhoqo. Ngokuxhomekeka kwimeko, olunye uhlobo lobugcisa lunokunika iinkonzo zokulawula iimeko. Umzekelo, umntu onika iinkonzo zokulawula iimeko kwiziko lokusebenzisa izixhobo zokusetyenziswa kakubi ngokweziyobisi angenakho imvelaphi yokuxiliswa kweziyobisi ngokweziyobisi. Akuqhelekanga ukuba ulawulo lwentlawulo lwenziwa ngabaqeshwa bezentlalo zonyango.
Ukufumana ulwazi oluthe xaxa malunga nesibonelelo somphathi weefowuni, jonga iKomishoni yeCandelo loQeqesho loMphathi.
> Imithombo:
> I-American Nurses Credentialling Centre (I-Subsidiary of the American Nurses Association), Ulawulo lweCandelo loLondolozo.
> Isebe lezeMpilo laseMelika kunye neNkonzo zeNtlalo, i-Arhente yoPhando lwezeMpilo kunye noPhuculo, iiNzuzo zolawulo lwexesha lokugula okungapheliyo, ngoFebruwari 2013.