Uma Umshwalense Wezempilo Ulahla Ukumboza Ukuvakashelwa kwe-ER
Uma usule nje umunwe wakho etafuleni ubone, kuhle kakhulu ukuthi igumbi lokuphuthumayo kufanele libe yisitoreji sakho esilandelayo. Kodwa akuzona zonke izimo eziphuthumayo ezicacile.
Amakamelo okuphuthumayo yizindawo ezibiza kakhulu ukuthola usizo lwezokwelapha, ngakho-ke izimo ezingekho eziphuthumayo, abahlinzeki bamashuwalense bafuna amalungu abo ukuba asebenzise ezinye izindawo eziphansi, okubandakanya izikhungo zokunakekelwa okuphuthumayo noma ihhovisi lokuqala lokunakekela izingane.
Uma iziguli zisebenzisa izakhiwo ezingekho ze-ER, kungabizi kakhulu kumshuwalense, futhi lokho kuholela ezindlebeni eziphansi zokunakekelwa kwezempilo-kanye nezinkokhelo eziphansi zomshuwalense-wonke umuntu. Kodwa uma kwenzeka isimo esisongela ukuphila noma esiyilungu, igumbi lokuphuthumayo cishe liyindawo kuphela ehlomele kahle ukubhekana nezimo ezithile.
Futhi i-conundrum yukuthi abantu abaningi abaqeqeshwe ngomuthi ophuthumayo, ngakho-ke uma ungabaza ngokuqina kwesimo sezokwelapha, ukuphutha eceleni kokuqapha (okungukuthi, ukuya ekamelweni eliphuthumayo) ngokuvamile kubonakala sengathi kuyisisombululo esinengqondo kakhulu.
I-Anthem idala ukungqubuzana nemithetho emisha e-ER
Ngokuyinhloko, abanikazi besikhwama sezimali bayakhokha lezo zihambo ekamelweni eliphuthumayo. Kodwa i-Anthem ibangele ukungqubuzana nemithetho emisha eGeorgia, e-Indiana, e-Missouri naseKentucky (esebenza kahle ngoJulayi 1, 2017), lokho kushintsha izindleko ze-ER ukuvakashela isiguli uma ukubuyekezwa kwesimangalo kubonisa ukuthi isimo asiyiphuthumanga emva konke.
Isiguli esigcwaliswe yiVox siye ekamelweni eliphuthumayo eKentucky ngezinhlungu eziswini zomzimba nesifo somkhuhlane. Umama wakhe, owayengumhlengikazi owayengumhlengikazi, wameluleka ukuba ahambe ekamelweni eliphuthumayo, njengoba izimpawu zakhe zihlotshaniswa nokufakwa kwesicelo , okubhekwa njengesimo esiphuthumayo sezokwelapha. Kodwa kuthiwa wayenama-cysts ovarian esikhundleni salokho, into eyayibhalwe kuphela emva kokunakekelwa kwezokwelapha inikezwe ku-ER.
I-Anthem yamthumela isimemezelo esingaphezu kuka-$ 12,000, ethi isimangalo sakhe senqatshelwe ngoba wayesebenzise igumbi lokuphuthumayo ngenxa yokunakekelwa okuphuthumayo. Isigulane sathinteka, saqaphela ukuthi wayengazi ukuthi ukuhlupheka kwakhe kwakungesizimo eziphuthumayo kuze kube yilapho odokotela be-ER bethola ukuthi ukhona. Ekugcineni, ngemva kokukhala kwakhe kwesibili (nangemva kokuba isiguli sigxile indaba yakhe ngeVox), i-Anthem ikhokhele umthethosivivinywa.
I-ER Imithetho Ejwayelekile Izizathu Zokususa Izinhliziyo
Imithetho emisha ye-Anthem cishe ithinta ezinye iziguli eziningi kulawo mazwe amane. Kodwa izikweletu zezokwelapha ezimangalisa ezibangelwa uhambo oluya ku-ER akuzona ezintsha.
Ezinye zinezimiso ezifanayo zokubhalisa i-Medicaid, nge-copay ephakeme ngokungasebenzisi okuphuthumayo ekamelweni eliphuthumayo (nakuba kuhambisana nemithetho ye-Medicaid, ama-copays namanje asho uma kuqhathaniswa nezindleko zokunakekelwa okuhlinzekwe ku-ER).
Futhi abantu abangazitholi ngokuzenzakalelayo ku-ER abangaphandle kwenethiwekhi yabo yomshuwalense bangaqeda izikweletu ezinkulu zempilo, naphezu kokuthi i-ACA idinga izinhlelo ezingenakulinganiswa zezempilo ukumboza ukunakekelwa okuphuthumayo okuvela ngaphandle kwenethiwekhi njengokungathi ku- inethiwekhi.
Lezi zimangalo sezilokhu zihlolisiswa, kanye nabashuwalense abahlola kabili ukuqinisekisa ukuthi ukunakekelwa empeleni kwakuyiphuthumayo ngaphambi kokukhokha izikweletu ze-ER ezingaphandle.
Futhi noma ngabe umshuwalense ukhokha imali njengokuthi in-inethiwekhi, i-out-of-network ER akaphoqelekile ukwamukela ukukhokhwa kwe-insurer njengenkokhelo egcwele, ngoba i-ER ayinayo inkontileka nomshuwalense, futhi ingakwazi ukulinganisela ukukhokhela isiguli ukuthi ingxenye yesibambisomali isala ngemuva kokuba umshwalense akhokhe. Uma ngabe isisetshenziswa se-in-network, i-ER kwakuzodingeka ibhale ingxenye yesibambiso, ngaphansi kwemigomo yesivumelwano nomshuwalense. Kodwa ayikho imfuneko enjalo yezikhungo ezingaphandle kwenethiwekhi.
Uhlobo lokunakekelwa okuphuthumayo kwenza kube nzima iziguli ukuba zifinyelele emigodini yemishuwalense ezobe ingacacile.
Ezimweni ezingekho eziphuthumayo, abantu bavame ukubiza inkampani yabo yomshuwalense ukuthi bacele mayelana nokugunyazwa ngaphambi noma bahlole udokotela oyinhloko noma ukunakekelwa kwezingane ukuze ubone ukuthi kunakekelwa yini ukunakekelwa. Kodwa esimweni esiphuthumayo-noma okubonakala kubhekene nesimo esiphuthumayo, kusukela ekubhekiseni nesiguli-lezo zinto zingase zinganakiwe.
Futhi ingxenye enkulu, yile ndlela okufanele iyenze ngayo. Uma ngabe oshade naye enesifo sokushaya isisu, akufanele ukhathazeke ngokubiza inkampani yakho yomshuwalense-kufanele ubize u-911 noma ufike ku-ER ngokushesha ngangokunokwenzeka.
Kodwa uma abathengi bezwa izindaba mayelana nabalimi besikhwama sokuphika i-ER izikweletu ngoba umshuwalense kamuva uthatha isimo esingesilo oluphuthumayo, ngokuzwakalayo ukhathazeka. Isiguli esigatshaneni seVox sathi ngemuva kokuhlangenwe nakho ayekutholile nge-ER bill kanye ne-Anthem claim yokuphika, esikhathini esizayo "uzoya ekunakekelweni okuyinhloko, futhi kuyomelwe amphoqe [ukuba] angene e-ambulensi ukuze ahambe ekamelweni lokuphuthumayo. "
Qondisisa Inqubomgomo Yakho-Ngaphambi Kokuphuthumayo
Uma wazi ngokwengeziwe ukuthi uhlelo lwakho lomshuwalense wezempilo lusebenza kanjani, kungcono ukulungele ukuthi uzoba yizimo lapho uqedela ukudingeka ukusebenzisa ulwazi lwakho. Ngakho, isinyathelo sokuqala ukufunda ngokucophelela nokuqonda inqubomgomo yakho. Abantu bavame ukunamathela emgodini bese bekhohlwa kuze kube yilapho befuna ukukusebenzisa, kodwa akusikho isikhathi salokho esimweni esiphuthumayo. Ngakho-ke, ngesikhathi ongabhekene nesidingo esiseduze sokunakekelwa kwezempilo, hlala phansi nenqubomgomo yakho bese uqinisekisa ukuthi uyaqonda:
- Izindleko ezidonswe futhi ezingaphandle kwe-pocket ohlelweni lwakho, nanoma yisiphi i- copay esisebenza ku-ER ukuvakashelwa (inothi ukuthi ezinye izinqubomgomo zizoyeka i-copay uma ugcina ungeniswa esibhedlela nge-ER, futhi izindleko zizofaka isicelo i-deductible yakho-lezi yizinto ezizofuna ukuziqonda ngaphambi kwesikhathi, ngakho shayela inkampani yakho yomshuwalense bese ubuza imibuzo uma ungaqiniseki ukuthi uhlelo lwakho lusebenza kanjani).
- Kungakhathaliseki ukuthi uhlelo lwakho luhlinzekela ukunakekelwa kwe-out-of-network , futhi uma kunjalo, kungakhathaliseki ukuthi kukhona i-cap ezindleko zakho zokunakekelwa kwe-out-of-network. Ngaphezu kwalokho, uma kune-ER okungaphezu kweyodwa endaweni yakho, uzofuna ukuthola ukuthi yiziphi izinethiwekhi zenethiwekhi yakho nokuthi aziphi, ngoba lokho akuyona into ofuna ukukhathazeka ngayo ngesimo esiphuthumayo.
- Kungakhathaliseki ukuthi uhlelo lwakho lunomthetho ozoholela ekuphikeleni isimangalo sokusetshenziswa okungesiziphuthumayo kwe-ER. Uma kunjalo, zijwayeze nencazelo yakho yomshuwalense ngokuphuthumayo ngokungahambisani nokuphuthumayo. Uma imihlahlandlela ingabonakali icacile, shayela umshwalense wakho ukuze uxoxisane nalokhu, ukuze uqonde ukuthi yini okulindeleke kuwe ngokwemvelo yesikhungo okufanele usebenzise kuzo ezimweni ezehlukene (i-Anthem ichaze iziqondiso ezincwadini abathumele kumalungu ngo-2017, lapho imithetho yabo entsha eGeorgia, Indiana, Missouri, naseKentucky yaqala ukusebenza).
- Okushiwo yizimfuneko zakho zomshuwalense ngokwemigomo yokugunyazwa kwangaphambili kwezinqubo zokwelapha ezilandelayo ezivela ekuvakasheni kuka-ER.
Yini Okufanele Uyenze Uma Uthola Umthethosivivinywa E-ER ongalindelekile?
Uma uthola ibhilikithi elikhulu kunalindelekile ngemuva kokuvakashela ku-ER, finyelela ku-insurer yakho bese uqinisekisa ukuthi uyaqonda konke mayelana ne-bill. Ingabe ibhalansi ye-balance evela ku-ER ngaphandle kwenethiwekhi? Noma ingabe ukuphika kokumangalelwa ngoba umshwalense wakho ubheka isimo sakho okungesiyo esiphuthumayo? I-former ijwayele ukuvame kakhulu, kodwa futhi, ngeshwa, isimo lapho isiguli sinokuncane endleleni.
Uma uthola ibhalansi yesabelomali kusuka ku-ER ngaphandle kwenethiwekhi (ie, umshwalense wakho ukhokha ingxenye yesimangalo, kodwa i-ER ikukhokhela yonke into, futhi ungabhalisi noma yiziphi izinkokhelo ngoba ungenayo inkontileka nomshuwalense wakho), kunezinto ezimbalwa ongathanda ukuzenza:
- Hlola nomnyango womshuwalense wombuso wakho ukuze ubone ukuthi kukhona yini imithetho yokuvikelwa kwabathengi noma imithethonqubo esifundazweni sakho esibhekisele ukukhokhela ibhalansi ezimweni eziphuthumayo. Akukho mthethonqubo wesifundazwe ovimbela ukukhokhela ibhalansi kubanikezeli be-out-of-network, kodwa abanye bathi baye baxazulula le nkinga .
- Uma kungekho lutho uhulumeni wakho angakwenza, finyelela ku-ER ngaphandle kwenethiwekhi bese ubona ukuthi bazoxoxa nawe yini. Kungenzeka bazimisele ukwamukela imali encane njengokukhokha ngokugcwele.
Uma uthola isaziso sokuthi isimangalo sakho senqatshelwe ngoba umshwalense wakho uzimisele ukuthi isimo sakho asiyona into esiphuthumayo (futhi ukholelwa ukuthi ngempela kwakuyisimo esiphuthumayo noma okungenani lapho umuntu ohlakaniphile angayibheka khona isimo esiphuthumayo), unezinyathelo eziningi ngokwezinqubo zokudluliswa kwezicelo:
- Uma uhlelo lwakho lungakazalwa, i-ACA ikuqinisekisa ukuthi inqubo yesikhalazo sangaphakathi, futhi uma umshuwalense ephika isimangalo sakho, nawe uthola ukubuyekezwa kwangaphandle ngumuntu wesithathu ozimele (nansi isifingqo sokuthi izikhalazo inqubo yokusebenza).
- Ungaqala ngokuqalisa inqubo yesikhalazo sangaphakathi nomshuwalense wakho, futhi ngokufinyelela emnyangweni womshuwalense wombuso ukuze ubone ukuthi banakho isiqondiso kuwe.
- Gcina ithrekhi yalokho okwenzeka ngesikhathi senqubo yokufaka izicelo, kufaka phakathi amagama abantu owakhuluma nabo kanye nanoma yikuphi ukuxhumana okuthola kumklomelo wakho. Uzophinde ufune ukugcina isibhedlela esibhedlela, njengoba kungadingeka ukuthi uthumele ulwazi olwengeziwe kwenkampani yomshuwalense ukuze ubonise ukuthi isimo sakho siqinisekisa uhambo oluya ku-ER.
- Uma izikhalazo zangaphakathi nezingaphandle zingaphumelelanga, uzofuna ukubhekana nesimo esibhedlela. Bangase bazimisele ukunciphisa umthethosivivinywa noma ukusetha uhlelo lokukhokhela lokuphatha.
Ukuphikisana Kokuklanywa Kwezimangalo ER
Izindaba zemihlahlandlela entsha ye-Anthem eGeorgia, e-Indiana, eMissouri naseKentucky yahlangana nokukhala okuvela ezigulini nabathengi bomthengi. I-American College of Emergency Physicians ihlehlise emuva ngevidiyo edalwe ukugqokisa amaphutha ohlelweni olwenza ukuthi iziguli zikwazi ukuqonda ukuthi yini futhi akuyona into ephuthumayo, lapho ezinye izimo zingenakuhlolwa ngaphandle kokuhlola izivivinyo.
I-Anthem isho ukuthi indlela yabo yokusebenza isekelwe olimini olusezinkontileka zabo, nokuthi "inqubo yokuhlakanipha" isetshenziselwa ukusetshenziswa kodwa manje iphoqelelwa (okungukuthi, uma "umuntu ohlakaniphile" engakubheka njengokuphuthumayo, khona-ke Yisimo esiphuthumayo). Kodwa ngokucacile, lokhu kuyisinyathelo sokuphikisana. Iziguli, abahlinzeki bezokwelapha, nabathengi bamakhasimende bakhathazeka ngokuthi lo mkhuba ungasakazeka kubaningi bomshuwalense, ushiye iziguli ukungabi nandaba (ngesikhathi esingenakusihlwa) mayelana nokuthi ufuna ukunakekelwa ku-ER, okuholela emiphumeleni yezempilo engaba mpofu. Kodwa i-Anthem, futhi mhlawumbe ezinye izinkampani ezibhekele ukulandela, zigxile ekutheni zikhokhele izindleko zempilo-umsebenzi owenza wonke umuntu avumelane kuyadingeka, kodwa bambalwa abamukela ukuthi bangayifeza kanjani.
Futhi nakuba ukuphika kokumangalelwa kokusetshenziswa okungahlosiwe okuphuthumayo kwe-ER kungukuthi ukudala ukudideka nokukhathazeka, inkinga yezikweletu zezokwelapha ezimangazayo ngemuva kokuvakashelwa kwe-ER kube yinkinga eqhubekayo eyandulela inqubomgomo entsha ye-Anthem. Izifunda zomuntu ngamunye ziye zasebenza ukuxazulula inkinga kwezinye izimo, kodwa isaba inkinga ezindaweni eziningi zezwe.
Yize izixazululo zibonakala zibonakala uma zibhekwa ngombono wesiguli noma ummeli womthengi, kuyinselele ukuthola bonke abathintekayo ebhodini. Ngesikhathi esifanele, abathengi badinga ukuqonda okuningi ngangokunokwenzeka mayelana nokuthi ukuhlanganiswa kwabo kusebenza kanjani nokuthi yini amalungelo abo okudlulisa ukukhipha uma bezithola bephethe imali engalindelekile ngemuva kokuvakashela ku-ER.
> Imithombo:
> I-American College of Emergency Physicians. Amantombazane aphuthumayo aveza Inqubomgomo Yokunakekelwa Okuphuthumayo ye-Anthem ngevidiyo entsha. NgoJanuwari 17, 2018.
> Amasevisi e-Medicare naseMedicaid Services. Izimangalo zangaphakathi kanye neziKhalazo kanye nokubukezwa kohlelo lokubukwa kwangaphandle. Ngo-Ephreli 12, 2017.
> I-National Association of Insurance Commissioners, Imephu: Amazwe kanye neziNqumo.
> Pollitz, Karen. I-Kaiser Family Foundation. Izikweletu Zezokwelapha Ezimangalisa. Ngo-Mashi 17, 2016.