Do doctors have a duty to inform patients of alternative treatments?
Your doctor has the duty to inform you of any alternative treatments that another doctor would reasonably recommend when facing a patient with the same condition. To determine if malpractice occurred, you must be able to determine if another doctor would reasonably have made the same recommendation, or lack thereof, to you.
What questions should I ask my doctor about alternative treatments?
During your consultation with your doctor, ask him or her about the alternative treatments available to you. Ask why he or she made the recommendation you received and how its risks, benefits, and success rate compare to other available treatments.
What are optional LTSS benefits?
Optional LTSS benefits include home and community-based services, such as personal care attendants and adult day care, and institutional LTSS, such as intermediate care facilities for individuals with intellectual disabilities. Optional LTSS benefits can be provided under the state plan or through waiver programs.
What is an optional benefit waiver?
Once a state includes an optional service as part of its state plan, that service must be provided to all individuals eligible under all eligibility pathways that grant access to the traditional benefit package. Waivers offer more flexibility as they permit states to provide optional benefits only to specific groups and to cap enrollment.
Which of the following is an example of an optional Medicaid benefit?
The only two mandatory LTSS benefits provided to these beneficiaries are nursing facility and home health services. All other LTSS benefits are optional....OptionalCommunity supported living arrangementsOptometry servicesDental servicesPhysical therapy servicesDenturesPrescribed drugs12 more rows
Which of the following are mandatory benefits that must be provided by Medicaid programs in order to receive matching federal funding?
Mandatory BenefitsInpatient hospital services.Outpatient hospital services.EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services.Nursing Facility Services.Home health services.Physician services.Rural health clinic services.Federally qualified health center services.More items...
What does not deemed medically necessary mean?
When this denial is received, it means Medicare does not consider the item that was billed as medically necessary for the patient. A CO 50 denial cannot be resubmitted. It must be sent to redetermination.
When a patient is covered through Medicare and Medicaid which coverage is primary?
Medicaid can provide secondary insurance: For services covered by Medicare and Medicaid (such as doctors' visits, hospital care, home care, and skilled nursing facility care), Medicare is the primary payer. Medicaid is the payer of last resort, meaning it always pays last.
Which is considered a mandatory medical service that states must offer to receive federal matching funds?
Federal rules require state Medicaid programs to cover certain “mandatory” services, such as hospital and physician care, laboratory and X-ray services, home health services, and nursing facility services for adults.
Can you have Medicare and Medicaid at the same time?
Yes. A person can be eligible for both Medicaid and Medicare and receive benefits from both programs at the same time.
Who determines if something is medically necessary?
How is “medical necessity” determined? A doctor's attestation that a service is medically necessary is an important consideration. Your doctor or other provider may be asked to provide a “Letter of Medical Necessity” to your health plan as part of a “certification” or “utilization review” process.
What are the criteria used to determine medical necessity?
The determination of medical necessity is made on the basis of the individual case and takes into account: Type, frequency, extent, body site and duration of treatment with scientifically based guidelines of national medical or health care coverage organizations or governmental agencies.
What determines medically necessary?
"Medically Necessary" or "Medical Necessity" means health care services that a physician, exercising prudent clinical judgment, would provide to a patient. The service must be: For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms.
When the patient is covered by both Medicare and Medicaid what would be the order of reimbursement?
gov . Medicare pays first, and Medicaid pays second . If the employer has 20 or more employees, then the group health plan pays first, and Medicare pays second .
Can you have Medicare and another insurance at the same time?
It is possible to have both private insurance and Medicare at the same time. When you have both, a process called “coordination of benefits” determines which insurance provider pays first. This provider is called the primary payer.
Does Medicare automatically forward claims to secondary insurance?
If a Medicare member has secondary insurance coverage through one of our plans (such as the Federal Employee Program, Medex, a group policy, or coverage through a vendor), Medicare generally forwards claims to us for processing.
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States have the option to provide alternative benefits specifically tailored to meet the needs of certain Medicaid population groups, target residents in certain areas of the state, or provide services through specific delivery systems instead of following the traditional Medicaid benefit plan.
Alternative Benefit Plan Final Rule
A final rule, published on July 15, 2013, entitled, “Medicaid and Children's Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment” (CMS-2334-F) made major changes in the Medicaid Benchmark Requirements..
How many EHBs are covered by the ACA?
Under the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended), benchmark and benchmark-equivalent packages must now cover ten essential health benefits (EHBs) so that they align with plans offered through the individual and small group insurance markets.
What is an ABP in Medicaid?
Adults who become eligible for Medicaid under the new adult group must be offered an alternative benefit plan (ABP) that covers the 10 EHBs mandated by the ACA. States are not required to offer as part of this package all the benefits that it offers in traditional Medicaid.
What is alternative medicine?
Alternative medicine involves anything that is a break from the usual allopathic medications. This stream of treatment includes acupuncture, or herbal medicine, or energy healing, and other forms of healing that were earlier not considered a form of medication, especially in the West, whereas the methods are centuries-old practices in the East.
What are complementary and alternative care methods?
Complementary and alternative methods of patient care have been reported to benefit from these other forms of care that aim at mental well being in addition to reducing the physical pain and treating the symptoms. Energy healing and healing arts have been found to be especially beneficial for cancer patients exploring alternative care methods.
What is the treatment for a patient suffering from a disease?
These treatment methods include hospice care and palliative care —the treatment methods for patients suffering from certain diseases, or those requiring special care or treatments and care, which aim at alleviating the pain and minimizing the symptoms rather than treating the disease per se.
What is complementary medicine?
Complementary methods often aim to relieve the pain and minimize symptoms without interfering with the usual medication and treatment. Alternative medicine and care often does not limit itself to medication and treatment of physical symptoms, but also aims at targeting the mind, body, and spirit.
What is optional LTSS?
Optional LTSS benefits can be provided under the state plan or through waiver programs. Once a state includes an optional service as part of its state plan, that service must be provided to all individuals eligible under all eligibility pathways that grant access to the traditional benefit package.
What is the ACA 111-148?
111-148, as amended) mandates that many preventive services be provided with no cost sharing to individuals enrolled in exchange plans, Medicare, and Medicaid expansions to childless adults, who are often referred to as the new adult group ( HHS 2014 ).
What is non emergency transportation?
Non-emergency transportation to medical care 1. Early and Periodic Screening, Diagnostic, and Treatment services for individuals under age 21 (screening, vision, dental, and hearing services and any medically necessary service listed in the Medicaid statute, including optional services that are not otherwise covered by a state.
What are the mandatory benefits of LTSS?
The only two mandatory LTSS benefits provided to these beneficiaries are nursing facility and home health services. All other LTSS benefits are optional. Optional LTSS benefits include home and community-based services, such as personal care attendants and adult day care, and institutional LTSS, such as intermediate care facilities ...
What is tobacco cessation counseling?
Tobacco cessation counseling and pharmacotherapy for pregnant women. Laboratory and X-ray services. Sources: CMS and Social Security Act. 1 Federal regulations require states to provide transportation services; they may do so as an administrative function or as part of the Medicaid benefit package. Optional.
What is covered by the ADA?
In addition, regular preventive dental care and treatment to relieve pain and infections, restore teeth, and maintain dental health, as well as some orthodontia, is covered.
What is Medicaid LTSS?
Medicaid beneficiaries who use long-term services and supports (LTSS) are a diverse group that includes working adults with physical disabilities, children who are medically fragile, individuals age 65 and older, people with intellectual and physical disabilities, and individuals who are severely mentally ill.
What is alternative medicine?
The term “alternative medicine” describes any form of medicine or healing that does not fall into conventional medical practice. In the U.S. it refers to forms of medicine that are not widely accepted or practiced by medical doctors, particularly those that do not have as much scientific evidence to support them as more mainstream methods.
What is standard vs alternative medicine?
Standard vs. alternative medicine. Summary. The term “alternative medicine” encompasses a wide range of medical practices and systems from cultures around the world. In countries such as the United States, people use it to describe practices that are outside mainstream medicine. The term “alternative medicine” is subjective.
How does biofield therapy work?
Biofield therapies. These therapies aim to help people by manipulating invisible energy fields. According to some medical systems and practices, the energy around the body can influence health. By addressing disturbances or blockages in energy, practitioners believe it is possible to treat certain conditions.
What is holistic medicine?
Holistic medicine: This refers to treatment that considers a person’s health as a whole, rather than focusing on one organ or bodily system. Some types of alternative, complementary, and integrative medicine are also holistic. Some people group “complementary and alternative medicine” together under the acronym CAM.
What are the benefits of standard medical care?
One of the main benefits of standard medical care is that it undergoes rigorous research. Through clinical trials and studies, scientists can determine whether certain techniques, medicines, and courses of treatment are effective and safe. Many scientists use these methods to study alternative medicine, too.
What is a naturopathic system?
Naturopathy is a system that includes a mixture of traditional and alternative approaches to medicine. It focuses on using natural and noninvasive ingredients and techniques, such as herbs, exercise therapy, dietary changes, and massage, among many others.
Why is alternative medicine considered mainstream medicine?
Sometimes, something that begins as an “alternative” treatment can become part of mainstream medicine due to strong evidence that it works and has no safety risks.
Informed Consent to Treatment
Failure to disclose any relevant information about a medical procedure is an act of medical malpractice because it robs the patient of the ability to provide his or her informed consent to the procedure. Patients have the right to know what is being done to their bodies and why.
Identifying Alternative Treatment Methods and Discussing Them with your Doctor
Your doctor has the duty to inform you of any alternative treatments that another doctor would reasonably recommend when facing a patient with the same condition. To determine if malpractice occurred, you must be able to determine if another doctor would reasonably have made the same recommendation, or lack thereof, to you.
Work with an Experienced Chicago Medical Malpractice Lawyer
If you were not thoroughly educated about your treatment before you received it, your doctor could be guilty of negligence. If this negligence caused you to suffer financial damages, you could be entitled to recover compensation for these damages through a medical malpractice claim. To learn more, contact our team at Baizer Kolar, P.C.
Partial Hospital Program (PHP)
A PHP is an outpatient treatment setting. Programs are usually at least six hours per day, up to five days per week. PHP programs provide individual, group, and family therapy along with educational groups.
Intensive Outpatient Program (IOP)
An IOP is an outpatient treatment setting. Treatment times are usually shorter and less frequent than for PHPs. For example, an IOP may offer treatment three days per week for three hours per day. IOP programs provide individual, group, and family therapy along with educational services.
Outpatient Behavioral Health Services
Outpatient behavioral health services consist of office-based individual, group, and family therapy with a private therapist.
Inpatient Detoxification (Detox)
If you are physically addicted to a substance or substances, or have been using substances in large amounts, you may require medically supervised withdrawal to avoid complications from the substance you have used. Please note: Inpatient detoxification is not a comprehensive treatment — however, it is often the first step on the path to recovery.
Rehab or Residential Treatment Center (RTC)
This level of care is sometimes needed after inpatient detoxification. It is also available for those who do not require detoxification, but who may need 24-hour care.
Medication Assisted Treatment (MAT)
Proper use of certain medications can help individuals combat the physical opioid addiction and can offer relief, as well as support in other areas. Established evidence indicates that MAT is a highly effective approach to preventing overdoses and death for people living with opioid addiction.
