HSA 515 SU Wk 8 Healthcare Policy Law Ethics & Administrator Role Presentation
HSA 515 SU Wk 8 Healthcare Policy Law Ethics & Administrator Role Presentation
ole of the Health Care Administrator Presentation
Introduction
By now you know that administrative responsibilities in health care facilities are managed by professionals who oversee medical facility processes, have in-depth knowledge of regulatory requirements, and have a thorough understanding of the complexities involved in patient care. Drawing upon what you have learned in this course, imagine you have been invited to an annual meeting for a large national health care company. You have been asked to speak to a group of managers and directors about the strategic role of health care administrators and must prepare a comprehensive overview of the political, legal, and ethical aspects of the health care administrator’s role.
Instructions
For this assignment, create a professional, narrated presentation focused on the political, legal, and ethical aspects of the health care administrator’s role. Your target audience are professionals in the industry who do not have a thorough understanding of your work.
Create a PowerPoint (or Prezi) and record the presentation using Kaltura. Follow the content outline below and use speaker notes to cover the required topics listed here:
Provide an overview of the political, legal, and ethical aspects specific to the health care administrator’s role (2–3 slides).
Summarize how the different aspects identified in 1., above, overlap and interface (1–2 slides).
Provide three examples of the duties and responsibilities involved in health care administration, such as risk management, policy and procedure, regulatory compliance, ethics board, compliance officer, et cetera (2–3 slides).
List two types of jobs or titles often found in health care delivery settings that are focused on risk management and regulatory compliance; include review of the importance and benefits of these functions within the health care system (1–2 slides).
Summarize how the political, legal, and ethical issues affect patients and staff including the patient benefits (2–3 slides).
Summarize how the political, legal, and ethical issues affect the financial and business operations of a health care facility (2–3 slides).
Summarize the health care administrator’s role in regard to political, legal, and ethical issues related to an issue such as a data breach, a HIPAA or EMTALA violation, et cetera). Review the implications of this function if mishandled. (2–3 slides)
Note: The presentation should not exceed 15 slides (with speaker notes) including a title slide and reference slide.
Grading Criteria
The grading criteria for this presentation is as follows. It must include the elements listed below so be sure to address each point. You may also want to review the performance level descriptions for each criterion in the scoring guide to see how your work will be assessed:
Prepare an overview of the political, legal, and ethical aspects specific to the health care administrator’s role.
Summarize how the political, legal, and ethical aspects of the administrator’s role overlap and interface.
Analyze three examples of the duties and responsibilities involved in health care administration.
Evaluate two types of jobs found in health care delivery settings that are focused on risk management and regulatory compliance.
Analyze how political, legal, and ethical issues affect staff, patients, and business operations.
Create a professional slide presentation with speaker notes.
Use a minimum of three quality academic resources to support your strategy and decisions.
Common reasons for a denial and examples of appeal letters
Appealing an insurer’s decision can be overwhelming and confusing. Below we’ve provided helpful advice and examples of appeal letters to use when you ask your insurance company to reconsider their denial of coverage.
Not medically necessary
You must prove the medical provider thinks the recommended treatment is medically necessary. Ask your doctor—and perhaps other medical experts—to provide written documentation explaining why.
Example of a not medically necessary appeal letter (Word, 30KB)
Experimental
Experimental treatment may be covered if you or your medical provider can prove it meets one or more of the following conditions:
Medically necessary and considered standard treatment by the medical community.
The only treatment that will work (show what you’ve already tried).
Less expensive than standard treatment.
A procedure that’s been covered by your plan in the past for patients with the same medical condition. This is something your provider might know.
Example of an experimental treatment appeal letter (Word, 34KB)
Out of network
Try to show your plan didn’t have access to a provider with the needed specialty in-network, or there was an unreasonably long wait time for an in-network provider.
Example of an out-of-network provider appeal letter (Word, 31KB)
Health care setting (e.g. in-home care vs. hospitalization)
In-home care instead of hospitalization may be covered if you show that in-home care would be less expensive and will meet the medical needs of the patient. Show that your provider recommends the best care is in-home care instead of hospitalization. Provide an in-home care treatment plan approved from your provider.
Depending on the type of plan, it may help to cite state rules (leg.wa.gov).
Example of an in-home health care setting appeal letter (Word, 31KB)
Policy cancelled for lack of payment
Explain why the payment wasn’t made, such as a payroll error, or a new bank account was established and you forgot to notify the insurer of the account change. Explain that you have been a customer for a long time and have always made your payments on time. Ask your insurer to make a one-time exception and reinstate your coverage.
Example of a reinstatement appeal letter due to nonpayment (Word, 30KB)
External review by an independent review organization (IRO)
The external review is one of several steps in the appeal process when an independent third-party reviews your appeal to determine whether the insurer should cover your claim or not. It’s requested after you’ve exhausted your insurance company’s internal review process without success. To check out other IRO decisions for health insurance appeals, use our searchable database.
Example of requesting a second-level (external) review appeal letter (Word, 25KB)
