When medical necessity is disputed

With many people predicting passage of third-party-review and prudent-layperson legislation this year, some health plans may be forced to improve efforts to educate members about their own rules and procedures. A handful of HMOs surveyed by InterStudy Publications do not have written definitions of medical necessity that are applicable for dispute resolution, and more than a quarter do not make expense or benefit data for representative conditions available. Given that, it doesn't require a big leap to understand why the most common disputes HMOs faced in 1997 were related to rules — not diagnoses. One curious finding: While 95 percent of HMOs have a prudent-layperson standard for ER coverage, ER-claim denial was one of the most frequently appealed problems by HMO members.


Career Opportunities

HAP, a subsidiary of Henry Ford Health System, is a nonprofit health plan providing coverage to individuals, companies and organizations. This executive develops strategies to meet membership and revenue targets through products, pricing, market segmentation and advertising.  Aligns business among Business Development, Commercial Sales, Medicare and Public Sector Programs and Product Development. Seeks to enhance and be responsible for business development and expansion through the development of an effective product portfolio, strong interpersonal relationships and service excellence.

Apply via email to jfedder1@hfhs.org or online at http://p.rfer.us/HENRYFORDlXqAJA

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