employee wage deduction or fraud? 4. Jennifer Ellerhoff is the spouse of an E-5 ADSM stationed in Southeast Asia. She is enrolled in a family policy with TRICARE Select. On January 12, Jennifer has a medical encounter in a civilian outpatient clinic. The provider (a nonPAR) charged $240. This is the first medical encounter of the year for Jennifer and her two children. The TRICARE allowable charge (TMAC) for this procedure is $212. After the EOB is received, the clinic sends Jennifer a statement for $212. She calls and asks you why she has to pay this charge. How would you explain the reason why she owes this amount? 5. Some media reports have caused many Americans to view managed care, particularly HMOs, negatively. Obviously, not everyone has a clear picture of exactly what managed care is and how it functions. How can the general public be better informed so that managed care and traditional healthcare can be compared equitably and without bias? 6. You're newly employed as a health insurance professional with the Great Arch Medical Clinic in the state of Missouri. To maximize your on-the-job efficiency, you brought your health insurance professional notebook from your previous employment in the state of California. When it comes time to complete Blue Cross and Blue Shield forms at Great Arch, you refer to the claims completion guidelines from your notebook. What problems, if any, might you experience if you follow the California claims completion guidelines? 7. A patient can terminate a doctor-patient (implied) contract by simply paying the fee(s) associated with the procedures and/or services rendered and not returning to the practice. However, if the healthcare provider wants to terminate this same contract, he or she must follow specific guidelines before doing so to avoid abandonment. How do medical ethics play a role in this scenario? 8. Sharon Lassiter has a medical savings account (MSA). Her coworker, Neola Carlson, has a flexible spending account (FSA). Sharon and Neola think they have basically the same thing. Explain to them how these two methods of paying for healthcare costs are similar and how they differ. 9. After Darren Bossley suffered a job-related injury to his left hand and couldn't perform his regular job, his employer assigned him to alternative duties, which consisted of completing coursework for an electrician's apprenticeship. Bossley claimed that he was unable to complete the hours due to severe pain; however, his treating physician released him to return to work because the physician believed that Bossley was able to perform in this alternative work arrangement. Bossley was terminated from his job for failing to complete his work hours and for not reporting to work. As a result, his employer's workers' compensation insurer refused to pay disability benefits. Were Bossley's workers' compensation claims wrongly denied? 10. Dr. Argyle, your employer, has asked you to provide an "easily understandable" explanation of the Medicare Part D "donut hole" to one of his elderly patients. How would you explain this? 11. Medicaid pays for only what it considers medically necessary. If a patient requests a service/procedure that doesn't fall under this specific definition, what are their options? How can the health insurance professional determine medical necessity, and whose responsibility is it to know what services/procedures come under this description? 12. Most healthcare facilities today have computerized software programs that handle patient accounting. Therefore, students often ask, "Why do I have to understand basic accounting principles if computers can do it?" Why is it important for students to understand accounting basics? 13. As you prepare for a career as a health insurance professional, you should know your possible future. How can you plan for a successful career in healthcare ? 14. There's a long history regarding the value of hospital accreditation. In your opinion, is the accreditation process important? Why or why not? 15. Until 2019, the ACA contained an "individual mandate," which required everyone to have health insurance. A person who could not obtain health insurance through an employer was required to buy it through the exchanges. Why was this requirement in place? Part 3 1. Corrina Barclay had been suffering from a severe earache for several days. She made an appointment with otolaryngologist Amanda Morrison, whom she had not seen before. When Corrina arrived for her scheduled 2 pm appointment the next afternoon, Paula Troutman, the medical receptionist, checked her in and asked for her insurance ID card. Corrina, after searching through her purse, determined that she had left it at home She told Paula that she was employed with the local city police force and was enrolled in the city's group employer plan. The city's plan was through Blue Cross and Blue Shield and the ID numbers (at that time) were the same as the enrollees' Social Security numbers. Paula informed Corrina tha providing a Social Security number wasn't adequate, that it was the policy of the practice not to see new patients unless they could show proof of insurance, and that the doctor could not see her until she produced her insurance ID card. Corrina left without receiving treatment and went to the emergency room. Blue Cross and Blue Shield subsequently refused to pay the ER fees, stating that Corrina's medical problem wasn't a bona fide emergency. Was Paula ethically right in refusing to allow Corrina to see Dr. Morrison for treatment? How would you have handled this situation? Can you explain why Corrina could be treated in the ER without proof of insurance and not in a physician's office? 2. You're training a new assistant at the Mid-Prairie Health Clinic. He asks you to further explain the rationale of the CLIA program and what services provides. Answer his question. 3. Doris Westerly, a patient new to Medicare, is referred to your office and states, "The girl at the front desk said I would have to pay today's charge but that I shouldn't pay just yet. I'm very confused. Now that I'm on Medicare, I thought they would pay for my healthcare. She said I have to pay my medical bills until I reach a certain limit. What is this limit and how do I meet it?" Answer her question. 4. Medicaid fraud is a problem and a considerable waste of taxpayer dollars. The Affordable Care Act of 2010 required states and US territories to establish Medicaid Recovery Audit Contractor (RAC) programs. Medicaid RACs have the responsibility of identifying and recovering misspent Medicaid funds. Identify and discuss ways that you, as a health insurance professional, can learn more about and help combat Medicaid fraud. 5. Elaine Arlington calls the medical clinic where you're employed, asking to schedule an appointment for her 15-month-old son, Noah. When you inquire about insurance, Ms. Arlington explains that, even though she is employed part-time, she doesn't make enough money to be able to af even the cheapest plans on the exchange. She further explains that she isn't eligible for Medicaid because she earns too much at her job. She rage for