Moore's Passionate Plea for Change
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Provider Manual for Physicians, Hospitals and Healthcare Providers
Provider Manual For physicians, hospitals and healthcare providers 1 GHHKFMCEN IMO7451 Effective July 9, 2019 This page left blank intentionally. Table of Contents I. Overview of Humana and ChoiceCare 5 II. Contact Information 6 Online Provider Portals 6 Contact Us 8 III. Claims Procedures 9 Checking Member Eligibility 9 Member Identification (ID) Card 9 HumanaAccess Cards 10 Medical Coverage Policies, Clinical Trials 11 Claims Submission and Processing 11 Reimbursement 15 Overpayments: Humana Provider Payment Integrity 16 IV. Utilization Management 17 Preauthorization (Prior Authorization) 17 Referrals 19 Inpatient Coordination of Care/Concurrent Review 19 Clinical Review Guidelines 20 Peer-to-peer Review 20 Second Medical Opinions 21 Special Requirements for Hospitals 21 Special Requirements for SNFs, Home Health and Outpatient Rehab 23 V. Office Procedures 25 Office Appointments and Wait Times 25 Address Change and Other Practice Information 25 VI. Medical Records 26 VII. Provider Claims Dispute Process, Member Grievance/Appeal Process and Provider Termination Appeal Process 27 Provider Claims Dispute Process 27 Member Grievance/Appeal Process 28 Commercial Appeals 29 Medicare Appeals 30 Provider Termination Appeal Process 31 3 VIII. Covered Services 32 IX. Clinical Practice Guidelines 32 X. Compliance/Ethics 33 Liability Insurance 33 Compliance and Fraud, Waste and Abuse Requirements 33 Reporting Methods for Suspected or Detected Noncompliance or FWA 34 Reporting Occurrences 35 Conflicts of Interest 36 Medicare 36 XI. Product/Plan Overview 40 Health Maintenance Organization (HMO) 40 Preferred Provider Organization (PPO) 42 XII. Credentialing 42 XIII. Quality Management 43 XIV. Population Health Management 44 Population Health Management 44 Case Management Programs 45 XV. Humana EAP Section 48 Humana Employee-assistance Program (EAP) and Work-life Services 48 Contact us 48 Clinical services 48 Claims procedures 48 XVI. -
Not a Question of If, but When
PROLOGUE NOT A QUESTION OF IF, BUT WHEN IN THE INFORMATION AGE, THERE ARE TWO KINDS OF PEOPLE, TWO KINDS OF INSTITUTIONS, two kinds of organizations: those who have been hit with a crisis and those who haven’t been around very long. Whether you are a multinational corporation such as BP responding to oil gushing into the Gulf of Mexico or the neighborhood restaurant dealing with a bad Yelp review, confronting a crisis is not a question of if but of when. And of those who have looked a great crisis squarely in the eye, there are similarly two kinds of people, two kinds of institutions, two kinds of organizations: Those who were able to be masters of their disasters, and those who failed. The landscape is dotted with a few winners but crowded with many losers who simply did not have what it took to survive the crisis. For every Bill Clinton—who left office with the highest presidential job approval rating in history despite having been impeached—there are dis- graced former politicians like Gary Hart and John Edwards. For every Goldman Sachs—which, despite being widely portrayed in the wake of the 2008 financial meltdown as a pack of real-life Gordon Gekkos sav- agely trouncing all in their path in the service of the bottom line, has contin- ued to have great success—there are companies like Lehman Brothers, Enron, and Arthur Andersen, consigned to the ash heap of Wall Street. For every franchise athlete like Yankee’s star Alex Rodriguez—who in 2009 went from being the spring training goat of ridicule over revelations about his use of performance-enhancing drugs to being the 2009 World Se- ries hero—there are disgraced former superstars like Barry Bonds and Mark McGwire. -
Debunking the Government Takeover Myth
Debunking the Government Takeover Myth By Stan Dorn and Stephen Zuckerman Of the many unfounded claims now coloring the health care debate, at least one can be taken off the table. As President Obama told the nation September 9, it’s time to stop making “wild claims about a government takeover of health care.” He’s right and here’s why. For starters, pending legislation would leave our largely private medical care system intact. Right now, more than 90 percent of doctors are in private practice and 84 percent of all hospital admissions are to private facilities. That wouldn’t change as a result of any reform proposals. If it’s Big Brother in the examination room that seems chilling, that’s not at issue either. Nothing in the thousand pages of reform proposals would give the federal government any new authority to intervene in private health care decisions. “Death panels” are as imaginary as Lord Voldemort, and government’s role would be largely what it is now: helping low-income Americans pay for health coverage and regulating insurance companies so they better serve consumers. Under the new proposals millions of Americans would see their health care options increase. Workers covered through small firms, for instance, could choose from a range of health plans available in a new health insurance “exchange,” a convenient new marketplace that could make both private and public options available. Today, three fourths of these workers are offered only one health plan by their employer. And when people work for themselves or a company that doesn't provide any insurance at all, they are on their own today. -
A Call for Change: the Evolution of the Modern Documentary From
England | 1 A Call for Change: The Evolution of the Modern Documentary from Informative Media to Persuasive Platform Valerie England San Jose State University Communication Studies 145i: Rhetorical Criticism Gina Firenzi December 14, 2011 Abstract England | 2 In the past several years, new documentaries have begun to evolve from informative media to persuasive platform as a result of changing cultural contexts and ideologies. These four films – Sicko, Food Inc., Waiting for Superman, and Inside Job effectively utilize common narratives and themes to present audiences with calls for reform in critical areas such as food safety, quality education, access to healthcare, and financial regulation. This shift reflects a transformation of the valuation of knowledge and how it serves various conflicting group interests. In an increasingly materialistic and visual culture, where media holds hegemonic sway over mass audiences through its reinforcement of dominant meanings and perspectives, the “success” of a film is often understood by the public in terms of sales. Documentaries have suddenly become rather lucrative in the last several years and are enjoying large gains at the box office. Michael Moore’s Sicko , for example, wowed at $24.5 million in the United States alone. Others would argue that their success is rather limited, pointing out the one-sidedness of directors’ perspectives and apparent unwillingness to present all aspects to an issue. Success from this perspective is defined not by commercial gains but by objectivity and faithful representation of facts outside of personal belief or political agenda. The new documentaries shown in movie theatres are anything but; controversy surrounds many current releases, with sparks flying between critics who laud – or denigrate – the relative fairness of truths and conclusions presented to audiences. -
Advocate Health Partners
CONTRACT SUMMARY (Chicago PHOs) Risk Contract PLAN NAME/PRODUCT NAME/PLAN TYPE Managed by KEY OPERATIONAL ITEMS APP* Advocate Meridian Health Plan of Illinois Referrals and Claims managed/paid by Medicaid HMO Meridian Aetna Referrals and Claims managed/paid by Aetna Aetna HMO/POS/EPO/PPO Aetna Open Choice PPO Aetna Whole Health will no longer be offering Aetna Choice POS the Individual Market Place Product as of Aetna Choice POS II 1/1/2017. Aetna Whole Health products will Aetna HMO continue to be offered to Employers Groups Aetna QPOS (Self and Fully Insured) until 12/31/2018. Aetna Select Open Access Aetna Select State of Illinois = SOI Aetna Open Access HMO Aetna Elect Choice HMO (includes Aetna Health Funds) Aetna Open Access Elect Choice (includes Aetna Health Funds) Aetna Health Network Only Aetna Health Network Option Aetna Open Choice PPO – State of Illinois-SOI Aetna HMO (Formerly Coventry HMO) - SOI Aetna Choice POS II (Formerly Coventry OAP)-SOI Managed Choice POS Managed Choice Open Access PPO National Advantage Program (NAP) PPO Signature Authority (ASA or SRC) PPO Aetna Whole Health Beech Street / PPO Next PPO Only PPO products included in this agreement *Risk Managed by APP indicates when claims are paid by Advocate Physician Partners and when referrals are submitted through ERMA 1 Updated 1/1/2018 CONTRACT SUMMARY (Chicago PHOs) Risk Contract PLAN NAME/PRODUCT NAME/PLAN TYPE Managed by KEY OPERATIONAL ITEMS APP* Blue Cross Blue Shield Illinois Claims and Referrals are paid/managed by BlueCare -
In the United States District Court Northern District of Texas Dallas Division
Case 3:16-cv-02919-B Document 69 Filed 11/21/16 Page 1 of 97 PageID <pageID> IN THE UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF TEXAS DALLAS DIVISION HUMANA INSURANCE COMPANY, a § Wisconsin Corporation, ET AL., § § Plaintiffs, § § V. § No. 3:16-cv-2919-B § TENET HEALTH SYSTEM, a Texas § Corporation, § § Defendant. § MEMORANDUM OPINION AND ORDER Plaintiffs Humana Insurance Company, Humana Health Plan, Inc., Humana Health Plan of California, Inc., and Arcadian Health Plan, Inc. (collectively, “Humana” or “Plaintiffs”)1 and Defendant Tenet Health System (“Tenet” or “Defendant”) are parties to two hospital capitation participation agreements. The parties disagree about the termination dates of these agreements and have submitted the dispute to arbitration. Pending the arbitration panel’s decision, Humana seeks a preliminary injunction from this Court to maintain the status quo and stay the effect of Tenet’s notice of termination. Plaintiffs’ Amended Motion for a Preliminary Injunction [Dkt. No. 14] is now before the undersigned United States magistrate judge for decision and ruling pursuant to 28 U.S.C. § 636(c). See Dkt. No. 55. 1 The Court will, for ease of reference only, treat “Humana” as a singular noun when referring to Plaintiffs collectively as “Humana.” -1- Case 3:16-cv-02919-B Document 69 Filed 11/21/16 Page 2 of 97 PageID <pageID> The Court has considered the Amended Motion for a Preliminary Injunction [Dkt. No. 14], Tenet’s response [Dkt. No. 22], Plaintiffs’ reply [Dkt. No. 28], Tenet’s further response [Dkt. No. 43], the parties’ Joint Report re Request for Hearing on Motion for Preliminary Injunction [Dkt. -
485 Svilicic.Vp
Coll. Antropol. 37 (2013) 4: 1327–1338 Original scientific paper The Popularization of the Ethnological Documentary Film at the Beginning of the 21st Century Nik{a Svili~i}1 and Zlatko Vida~kovi}2 1 Institute for Anthropological Research, Zagreb, Croatia 2 University of Zagreb, Academy of Dramatic Art, Zagreb, Croatia ABSTRACT This paper seeks to explain the reasons for the rising popularity of the ethnological documentary genre in all its forms, emphasizing its correlation with contemporary social events or trends. The paper presents the origins and the de- velopment of the ethnological documentary film in the anthropological domain. Special attention is given to the most in- fluential documentaries of the last decade, dealing with politics: (Fahrenheit 9/1, Bush’s Brain), gun control (Bowling for Columbine), health (Sicko), the economy (Capitalism: A Love Story), ecology An Inconvenient Truth) and food (Super Size Me). The paper further analyzes the popularization of the documentary film in Croatia, the most watched Croatian documentaries in theatres, and the most controversial Croatian documentaries. It determines the structure and methods in the making of a documentary film, presents the basic types of scripts for a documentary film, and points out the differ- ences between scripts for a documentary and a feature film. Finally, the paper questions the possibility of capturing the whole truth and whether some documentaries, such as the Croatian classics: A Little Village Performance and Green Love, are documentaries at all. Key words: documentary film, anthropological topics, script, ethnographic film, methods, production, Croatian doc- umentaries Introduction This paper deals with the phenomenon of the popu- the same time, creating a work of art. -
Republican Leader Michael C. Burgess, MD
Republican Leader Michael C. Burgess, M.D. Energy and Commerce Health Subcommittee “Proposals to Achieve Universal Health Care Coverage” December 10, 2019 As Prepared for Delivery Thank you, Madam Chair. Thank you for holding this hearing on various universal heath care coverage proposals, including Medicare for All. Ranking Member Walden and I requested a hearing on Medicare for all numerous times this year, and I appreciate that you took our request seriously enough to hold today’s hearing. I would like to ask unanimous consent that our two letters be included in the record. Coverage does not equal care. Chairman Pallone and Chairwoman Eshoo stated in noticing this hearing that “universal health care coverage has long been the North Star of the Democratic Party.” Every bill before us today is paving that road to the North Star – to accomplishing one-size-fits-all health care coverage. Page 1 of 6 I’m not sure the three wise men would appreciate your comparison, as this North Star journey would lead our health care system as we currently know it to disintegrate into ashes. If we’re listening to Joni Mitchell, then the northern star is not very reliable as it is constantly in the dark. Medicare for All would eliminate private insurance, employer- sponsored health insurance, Medicaid, and the Children’s Health Insurance Plan, upon which many Americans depend. I am concerned about the consequences for existing Medicare beneficiaries, as this policy would raid the Medicare Trust Fund, which is already slated to go bankrupt in 2026. Our nation’s seniors have been depending on the existence of Medicare for their health care needs in retirement for their entire lives. -
Medicare Plans Referrals Required AARP Medicare Complete AARP
Insurance Sheet Commercial Medicare Plans Referrals Required If the Third Party Administrator uses one of AARP Medicare Complete AARP Medicare Complete Plan H4514-007 these networks, we can see the patient Aetna Medicare Aetna Select Access Direct BCBS HealthSelect Medicare Aetna HMO BCBS Medicare Advantage PPO & HMO (Carrell, TOA, AOSM Aetna bill/auth legacy grp) Austin State Hospital BCBS HealthSelect (formerly with UHC) - (Carrell, TOA, BCBS (Carrell, TOA, AOSM bill/auth legacy grp) Cigna Medicare Advantage AOSM bill/auth legacy grp) BCBS COA Blue Essentials (formerly with UHC) - (Carrell, BeechStreet (multiplan) Connected Senior Care Advantage Aetna (Austin) TOA, AOSM bill/auth legacy grp) BCBS TRS ActiveCare Blue Essentials (formerly w/Aetna) - Cigna Connected Senior Care Advantage Humana (Austin) (Carrell, TOA, AOSM bill/auth legacy grp) Blue Essentials (formerly HMO Blue) - (Carrell, TOA, AOSM Coventry/First Health Commercial Connected Senior Care Advantage WellCare (Austin) bill/auth legacy grp) Custom Ink Friday Health Plan Medicare Advantage Cigna HMO (written from PCP) Decent Healthcare Humana Medicare Humana HMOx Fairprice Network Medicare DME Jurisdiction A, B, C and D Humana Medicare Gold Plus HMO First Care (Scott & White) Medicare Novitas Solutions Texas Free Market (requires voucher) Molina Medicare Replacement and Dual -OLS pending, bill First Health and auth legacy group Texas Workforce Commission (DARS) (purchase order) Tricare Prime and Direct Care - Note: confirming existing Friday Health Plan Oscar Medicare Advantage -
Copyright by Leah Michelle Ross 2012
Copyright by Leah Michelle Ross 2012 The Dissertation Committee for Leah Michelle Ross Certifies that this is the approved version of the following dissertation: A Rhetoric of Instrumentality: Documentary Film in the Landscape of Public Memory Committee: Katherine Arens, Supervisor Barry Brummett, Co-Supervisor Richard Cherwitz Dana Cloud Andrew Garrison A Rhetoric of Instrumentality: Documentary Film in the Landscape of Public Memory by Leah Michelle Ross, B.A.; M.A. Dissertation Presented to the Faculty of the Graduate School of The University of Texas at Austin in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy The University of Texas at Austin December, 2012 Dedication For Chaim Silberstrom, who taught me to choose life. Acknowledgements This dissertation was conceived with insurmountable help from Dr. Katherine Arens, who has been my champion in both my academic work as well as in my personal growth and development for the last ten years. This kind of support and mentorship is rare and I can only hope to embody the same generosity when I am in the position to do so. I am forever indebted. Also to William Russell Hart, who taught me about strength in the process of recovery. I would also like to thank my dissertation committee members: Dr Barry Brummett for his patience through the years and maintaining a discipline of cool; Dr Dana Cloud for her inspiring and invaluable and tireless work on social justice issues, as well as her invaluable academic support in the early years of my graduate studies; Dr. Rick Cherwitz whose mentorship program provides practical skills and support to otherwise marginalized students is an invaluable contribution to the life of our university and world as a whole; Andrew Garrison for teaching me the craft I continue to practice and continuing to support me when I reach out with questions of my professional and creative goals; an inspiration in his ability to juggle filmmaking, teaching, and family and continued dedication to community based filmmaking programs. -
Racing Extinction
Racing Extinction Directed by Academy Award® winner Louie Psihoyos And the team behind THE COVE RACING EXTINCTION will have a worldwide broadcast premiere on The Discovery Channel December 2nd. Publicity Materials Are Available at: www.racingextinction.com Running Time: 94 minutes Press Contacts: Discovery Channel: Sunshine Sachs Jackie Lamaj NY/LA/National Office: 212.548.5607 Office: 212.691.2800 Email: [email protected] Tiffany Malloy Email: [email protected] Jacque Seaman Vulcan Productions: Email: [email protected] Julia Pacetti Office: 718.399.0400 Email: [email protected] 1 RACING EXTINCTION Synopsis Short Synopsis Oscar®-winning director Louie Psihoyos (THE COVE) assembles a team of artists and activists on an undercover operation to expose the hidden world of endangered species and the race to protect them against mass extinction. Spanning the globe to infiltrate the world’s most dangerous black markets and using high tech tactics to document the link between carbon emissions and species extinction, RACING EXTINCTION reveals stunning, never-before seen images that truly change the way we see the world. Long Synopsis Scientists predict that humanity’s footprint on the planet may cause the loss of 50% of all species by the end of the century. They believe we have entered the sixth major extinction in Earth’s history, following the fifth great extinction which took out the dinosaurs. Our era is called the Anthropocene, or “Age of Man,” because evidence shows that humanity has sparked a cataclysmic change of the world’s natural environment and animal life. Yet, we are the only ones who can stop the change we have created. -
Sicko: Michael Moore's Latest Fantasy
SiCKO: Michael Moore’s latest fantasy Michael Tanner ichael Moore’s newest film, Prize in Medicine are either US citizens or healthy Canadians who claim that they have Sicko, opened in June in the work there. With no price controls, free- no problem getting care. Yet nearly 800,000 MUnited States, and will open in market US medicine provides the incen- Canadians are not so lucky. No less an au- Australia in August. As one might expect of tives that lead to innovative breakthroughs thority than the Canadian Supreme Court a film attacking the US health system, the in new drugs and other medical technolo- has pointed out that many Canadians wait- early reviews have been close to ecstatic. But gies. US companies have developed half ing for treatment suffer chronic pain and perhaps the most telling review came from of all the major new medicines introduced that ‘patients die while on the waiting list’. Time magazine reporter Richard Corliss, worldwide over the past 20 years. In fact, Similarly, Moore shows happy Britons who rejoiced that ‘the upside of this popu- Americans played a key role in 80 per cent who don’t have to pay for their prescrip- list documentary is that there are no policy of the most important medical advances of tion drugs. But he didn’t talk to any of the wonks crunching numbers…’ the past 30 years. 850,000 Britons waiting for admission to Of course. We wouldn’t want anyone Instead, Moore focuses on life expec- National Health Service hospitals. Every who knows something about health care tancy, suggesting that people in Canada, year, shortages force the NHS to cancel as messing up Moore’s fantasy with facts.