Ingabe inkampani yakho yomshuwalense wempilo ikunikeze umphathi wamacala? Ingabe ubonwa ngumphathi wecala esibhedlela noma kwenkampani yezempilo ekhaya? Ingabe ungumhlengikazi ofuna ukuba umphathi wamacala? Awuqiniseki kahle ukuthi imenenja yamacala yenzani, kungani udinga eyodwa, noma yini ozoyenza uma waba umphathi wezinkinga? Nansi okudingeka ukwazi.
Ukuphathwa kwe-Case kungasho izinto ezehlukene ezindaweni ezahlukene
Okokuqala, kufanele wazi ukuthi yimuphi umphathi wamacala owenzayo kuncike ekulungisekeni okusebenza kuyo.
Isibonelo, umphathi wezehlakalo osebenzela inkampani yokunakekelwa kwezempilo ekhaya uzohlinzeka ngamasevisi ahlukene kakhulu kunomphathi wezinkampani kwenkampani yomshuwalense wezempilo, inkampani yomshuwalense wezinkokhelo zabasebenzi, noma esibhedlela.
Noma kunjalo, kunezinto ezithile ezihambisanayo kuzo zonke izindima zokuphathwa kwecala. Ngokufanayo, abaphathi bamacala bahlola izidingo zesiguli kanye nezinsiza ezikhona. Abaphathi bamacala bazama ukuthola indlela engcono kakhulu, ephumelelayo kakhulu, engokwenyuka ngokwezomnotho yokuhlangabezana nezidingo zesiguli ngezinsiza ezikhona.
Futhi ikakhulukazi ngezimo ezingokwemvelo ezingathí sina, ukuphathwa kwecala kungabangela imiphumela engcono yeziguli, ukuhambisana kangcono neseluleko sezokwelapha, kanye nokuzimela okungcono kwesiguli - nakuba kunemingcele emibikweni yokuphathwa kwecala. Nazi ezinye izibonelo zalokho umphathi wamacala akwenze kuzilungiselelo ezahlukene.
Isiphathimandla se-Case Case
Umphathi wezehlakalo esibhedlela ngokuvamile ungumhlengikazi owenza kokubili ukubuyekezwa nokusetshenziswa kokuhlelwa kokusetshenziswa .
Ukubuyekezwa kokusetshenziswa kuhilela ukuqinisekisa ukuthi isiguli sithola ukunakekelwa okudingekayo ngokwemithi futhi siyifake esimweni esifanele. Ukuhlela ukukhishwa kuyinkqubo yokubikezela iziguli eziqhubeka nezidingo zezokwelapha ngemuva kwesibhedlela bese zihlela uhlelo lokuhlangabezana nezidingo. Iziphathimandla ze-Hospital case ziyizinhloko ekuhleleni izidingo zokunakekelwa okuyinkimbinkimbi phakathi nesikhathi nabahlinzeki .
Isibonelo, kungumphathi wezehlakalo esibhedlela oqinisekisa ukuthi inkampani yomshuwalense wezempilo uyaqonda ukuthi kwenzekani ngesikhathi esibhedlela sesiguli. Uqinisekisa ukuthi umshuwalense unolwazi oludinga ukuvuma ukukhokhelwa esibhedlela futhi usebenza ukuvimbela ukuphikiswa kwesimangalo somshuwalense. Uxhumana nomphathi we-insurer yezempilo nsuku zonke noma zonke izinsuku ezimbalwa.
Nguye ohlela isiguli ukuba nokuvakashelwa ekhaya evela kumhlengikazi ovakashele ngemuva kokukhishwa esibhedlela, noma ukuthola ukuvuselelwa kwesifo esibucayi esiteshini sokuvuselela iziguli. Nguye osiza isiguli ukhethe inkampani yezempilo yasekhaya noma isikhungo sokuvuselela iziguli esise-inethiwekhi nomshuwalense wakhe futhi siyomamukela njengesiguli.
Ngaphezu kwalokho, umphathi wezehlakalo esibhedlela angase axoxisane ngezinzuzo zokuhlanganisa phakathi kwe-insurer yezempilo, umhlinzeki, nesiguli. Nasi isibonelo: Mhlawumbe isiguli esinesifo sengculaza esingapheli sinempilo ngokwanele sokuya ekhaya esibhedlela bese sithola ama-antibiotic akhe e-IV ekhaya emasontweni amathathu alandelayo. Kodwa-ke, inqubomgomo yomshuwalense wezempilo isiguli ayifihli izidakamizwa ze-IV noma imishini efana ne-tubing IV namapompo ukuthi isiguli sidinga ukuthola lesi sidakamizwa ekhaya.
I-pharmacy ekhaya i-IV ifuna isiguli ukuba sikhokhe imali engu-5 000 ephaketheni lakhe ukuze kutholakale izidakamizwa nemishini.
Umphathi wezocansi angase axoxisane nekhemisi lasekhaya lasekhaya, inkampani yokunakekelwa kwezempilo ekhaya, umshuwalense wezempilo, kanye nesiguli. Mhlawumbe uthola isiguli ukuthi sivume ukukhokha imali eyizigidi eziyizinkulungwane ezingu-1 000 ezibiza izindleko zemithi nemishini ngakho akudingeki ukuba ahlale esibhedlela amanye amasonto amathathu.
Ubuye athole ikhemisi lekhaya i-IV ukunciphisa izindleko zemithi nemishini nge $ 1,000. Uthola inkampani yokunakekelwa kwezempilo yekhaya ukuvuma ukuthatha ithebhu yamaphampu we-IV ukumnika ngezindleko zamaRandi ayi-500.
Uthola inkampani yomshuwalense wezempilo ukuthi avume ukukhokha ikhemisi imali engamaRandi ayizinkulungwane ezingu-2 500 nakuba kungadingeki ngoba ayiyona inzuzo ehlanganisiwe kumgomo wesiguli.
Umshuwalense uzimisele ukukhokha u-$ 2,500 ngakho ngeke kudingeke aqhubeke nokukhokha isibhedlela ngezinsizakalo zesiguli. Inkampani yezempilo yasekhaya izimisele ukukhokha u-$ 500 ngamapompo ngoba uma kungenjalo, isiguli ngeke sibuyele ekhaya futhi ngeke sidinge izinsizakalo zokunakekela ukunakekelwa kwezempilo ekhaya. Ikhemisi izimisele ukunciphisa intengo yemithi kanye nemishini nge $ 1000 ngoba ukwenza inzuzo encane kungcono kunokuba ungabi nhlobo nhlobo uma isiguli singakhishwa.
Umphathi wezeMpilo weKhaya laseKhaya
Imenenja yezokwelapha yezempilo ekhaya ihlukile kumphathi wezehlakalo esibhedlela ngoba ngokuvamile uhlinzeka ngokunakekelwa kwesiguli ngezandla. Ngaphezu kwalokho, uqondisa izinsizakalo zamanye amalungu eqembu lezokunakekelwa kwezempilo kanye nabanakekeli, uxhumana nenkampani yomshuwalense wezempilo, uxhumana nodokotela wegulane, futhi uqondise abanye abahlengikazi abavakashelayo noma abasizo lwezempilo ekhaya abanikeza ukunakekelwa kwesiguli.
Ngokufakelwa okuvela esigulini nasemndenini, umphathi wezinkinga zokunakekelwa kwempilo ekhaya uhlakulela uhlelo lokunakekelwa kwesiguli futhi ulunikeze odokotela isiguli ukuze avunyelwe ukugcina. Uhlela ukuqaliswa kwalolu hlelo ngesiguli, abahlinzeki bezinsizakalo ezidingekile, futhi ulungise uhlelo uma kudingeka.
Umphathi wezeMpilo ye-Insurance Company Company
Umphathi wenkampani yomshuwalense wezempilo uthola ulwazi kusuka kubaphathi bamacala esibhedlela, izinkampani zokunakekelwa kwezempilo ekhaya, amahhovisi odokotela, abasebenzi bezenhlalakahle nabanye abahlinzeki bezempilo. Ngokwe-insurer kanye nendawo, angase abuyele esibhedlela esibhedlela.
Umgomo wakhe ukuqinisekisa ukuthi isiguli sithola ukunakekelwa kwempilo okudingekayo, ukunakekelwa kwekhwalithi, nokuthi ukunakekelwa kunikelwa ngendlela efanele nangokomnotho ngangokunokwenzeka. Ukulindela izidingo zokunakekelwa kwezempilo esikhathini esizayo futhi uzama ukufaka izindlela zokuhlangabezana nazo zonke izidingo ngendlela efanele.
Kwezinye izinkampani zomshuwalense wezempilo, angase anciphise umkhawulo wakhe womsebenzi ezigulini ezinenkinga ethile yesifo esingapheli. Isibonelo, uma esebenza kuphela neziguli ze- rheumatoid arthritis , inguchwepheshe ekuxhumaniseni ukunakekelwa kweziguli ze-RA futhi angalindela izidingo zabo zokunakekelwa futhi asebenzise ngendlela efanele ukuhlangabezana nezidingo. Angakwazi ukusika nge-tape ebomvu futhi angase abe namandla okufinyelela ngaphezu kwezinzuzo ezihlanganisiwe zenqubomgomo yomshuwalense wezempilo futhi avumele izinto noma izinsizakalo ezingezona empeleni zihlanganiswe inqubomgomo yomshuwalense wezempilo kodwa lokho kuzovumela ukunakekelwa ukuthi kuhanjiswe ngokuphumelelayo futhi kulondoloze imali ngokuhamba kwesikhathi. Usebenza ukuhlangabezana nezidingo zesiguli ngenkathi egcina iso phansi kanye nemigomo yesikhathi eside.
Ubani Ukuphathwa Kwesikhashana?
Ukuphathwa kwamacala ngokuvamile kwenziwa ngabahlengikazi, kodwa hhayi njalo. Kuye ngokulungiselelwa, olunye uhlobo lochwepheshe lunganikeza ngezinsizakalo zokuphathwa kwamacala. Isibonelo, umuntu ohlinzeka ngamasevisi wokuphatha amacala enkampanini yokusebenzisa izidakamizwa ezingasebenzisa izidakamizwa angase abe nesizinda ekululekisweni kokusebenzisa kabi izidakamizwa. Akuyona into engavamile ukuba ukuphathwa kwecala kwenzeke ngabasebenzi bezenhlalakahle zezokwelapha.
Ukuze uthole ulwazi oluthe xaxa mayelana nesitifiketi semenenja yamacala, bheka iKhomishini yeComputer Certification Certification.
> Imithombo:
> Isikhungo se-American Nurses Credentialling (I-Subsidiary of American Nurses Association), Ukuphathwa Kwama-Nursing Case Management.
> UMnyango WezeMpilo waseMelika kanye Nezinsizakalo Zabantu, i-Agency for Healthcare Research and Quality, Izinzuzo zokuphathwa kwamacala okugula okungapheli, ngoFebruwari 2013.