Outline: Medicare Medicaid CHAMPUS Veteran's Affairs اصول مستندسازي پرونده پزشكي ازنظر قوانين سازمانهاي بيمه

What’s Medicare? Medicare is health insurance for: People 65 or older People under 65 with certain disabilities People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant) CMS, Revised June 2014

What does Medicare cover? Part A – Hospital Insurance Part B – Outpatient Medical Insurance Part C – Medicare Advantage plans Part D – Prescription Drug plans CMS, Revised June 2014

Part A (Hospital Insurance) helps cover: Inpatient care in hospitals Skilled nursing facility care Hospice care Home health care CMS, Revised June 2014

Part B (Medical Insurance) helps cover: Services from doctors and other health care providers Outpatient care Home health care Durable medical equipment Some preventive services CMS, Revised June 2014

Part C (Medicare Advantage): Includes all benefits and services covered under Parts A and B Usually includes Medicare prescription drug coverage (Part D) as part of the plan Run by Medicare-approved private insurance companies May include extra benefits and services for an extra cost CMS, Revised June 2014

Part D (Medicare prescription drug coverage): Helps cover the cost of prescription drugs Run by Medicare-approved private insurance companies CMS, Revised June 2014

What’s Medicaid? Medicaid is a joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid may also cover services not normally covered by Medicare. Each state has different rules about eligibility and applying for Medicaid CMS, Revised June 2014

eligibility for Medicaid 65 or older A child under 19 Pregnant Living with a disability A parent or adult caring for a child An adult without dependent children (in certain states) An eligible immigrant CMS, Revised June 2014

Benefits of Medicaid Doctor visits Hospital stays Long-term services and supports Preventive care, including immunizations, mammograms, colonoscopies, and other needed care Prenatal and maternity care Mental health care Necessary medications Vision and dental care (for children) CMS, Revised June 2014

Civilian Health and Medical Program of the United States (CHAMPUS) In 1966, enacted CHAMPUS. CHAMPUS was a medical insurance program for military retirees and their dependents. In 1994 Congress enacted law to establish the military TRICARE health system. Coverage active duty, their dependents military retirees and their dependents under age 65. military retirees and their dependents age 65 and over were excluded from military health care insurance. (eligible for Medicare)

Veteran's Affairs the Department of Veteran's Affairs is required by law to provide eligible veterans hospital care and outpatient care services that are defined as "needed.“ VA defines "needed" as care or service that will promote, preserve, and restore health.

VA member of the: Army, Navy, Air Force, Marine Corps, Coast Guard,

VA Health Care Eligibility Eligibility for VA health care is dependent upon a number of variables. These factors include:  the nature of a veteran's discharge from military service (e.g., honorable, other than honorable, dishonorable),  length of service,  VA adjudicated disabilities (commonly referred to as service-connected disabilities),  income level,  available VA resources among others.

What is Priority Group? VA places a priority on improved veteran satisfaction and maintains that their goal is to ensure the quality of care and service that veterans receive is consistently excellent, in every location, in every program.  Priority Group 1 Priority Group 1  Priority Group 2 Priority Group 2  Priority Group 3 Priority Group 3  Priority Group 4 Priority Group 4  Priority Group 5 Priority Group 5  Priority Group 6 Priority Group 6  Priority Group 7 Priority Group 7  Priority Group 8 Priority Group 8

Priority Group 1 Veterans with service-connected disabilities rated 50% or more disablingservice-connected Veterans determined by VA to be unemployable due to service-connected conditions

Priority Group 2 Veterans with service-connected disabilities rated 30% or 40% disabling

Priority Group 3 Veterans with service-connected disabilities rated 10% or 20% disabling Veterans who are former POWs (prisoners of war) Veterans awarded the Purple Heart Veterans whose discharge was for a disability that began in the line of duty Veterans who are disabled because of VA treatment or participation in VA vocational rehabilitation program

Priority Group 4 Veterans who are receiving aid and attendance or housebound benefits Veterans who have been determined by VA to be catastrophically disabled

Priority Group 5 Veterans receiving VA pension benefits Veterans who are eligible for Medicaid programs Veterans with income and assets below VA Means Test ThresholdsVA Means Test Thresholds

Priority Group 6 Veterans with 0% service-connected conditions, but receiving VA compensation Veterans seeking care only for disorders relating to Ionizing Radiation Veterans seeking care for Agent Orange Exposure during service in Vietnam Veterans seeking care for Gulf War Illness or for conditions related to exposure to during service in the Persian Gulf Veterans of World War I or the Mexican Border War Gulf War illness (GWI), is a chronic multisymptom disorder affecting returning military veterans and civilian workers of the Gulf War. A wide range chronic symptoms, including fatigue, muscle pain, cognitive problems, rashes and diarrhea. veteransGulf Warchronicsymptomsfatiguemuscle painrashesdiarrhea

Priority Group 7 Veterans who agree to pay specified copay with income and/or net worth above VA Income Threshold and income below the Geographic Means Test Threshold Geographic Means Test Threshold

Priority Group 8 Veterans who have been previously denied enrollment in the VA health care system because their income exceeded VA's income thresholds. These Veterans may now qualify if their household income does not exceed the current VA income thresholds by more than 10 percent. Veterans with income and/or net worth above the VA national income thresholds and the Geographic Means Test Threshold Geographic Means Test Threshold

موارد مربوط به اصول مستندسازي پرونده پزشكي ازنظر قوانين سازمانهاي بيمه

اصول مستند سازی 1- کليه فرم هاي پرونده بيمار بايستي اصل بوده و عناصر اطلاعات موجود آن تكميل گردد.  عدم استفاده از کاربن  عدم ثبت یا ثبت ناقص دستورات دارویی از قبیل نوع و تعداد و مقدار داروی مصرفی  عدم ثبت درخواست پزشک مبنی بر درخواست مشاوره 2- اطلاعات سر برگ فرم هاي ) شامل نام و نام خانوادگي ، شماره پرونده ، نام بخش ، تاريخ پذيرش و نام پزشك معالج و....( بطور کامل و دقيق ثبت و تكميل شود.  عدم وجود مشخصات بیمار در برگ شرح حال و برگه عمل جراحی 3- کليه موارد ثبت شده بايستي با درج نام و نام خانوادگي، مهر و امضاء مستند ساز تائيد و تصديق گردد. عدم تایید دستورات پزشک ، برگه شرح عمل جراحی عدم تایید مصرف هریک از داروها یا اقلام مصرفی توسط پرستار

4- در تمامي گزارش ها درج تاريخ و ساعت الزامي است. عدم درج تاریخ و ساعت دقیق ویزیت توسط پزشک معالج عدم ثبت دقیق شروع و خاتمه بیهوشی 5- مستندات و ثبتيات پرونده بيمار بايد حاوي اطلاعات واقعي، حقيقي و صريح باشند و از حدسيات، گمان ها و گفته هاي کلي و مبهم جهت ثبت اطلاعات استفاده نشود.  شرح کلی و فاقد جرییات عمل جراحی 6- کليه مستند ات بايستي واضح ، مداوم و پيوسته باشد. رعايت خوانا بودن ، مرتب بودن ، املاء صحيح ، نقطه گذاري و جمله بندي صحيح در ثبت اطلاعات ضروري است. ناخوانا بودن شرح عمل 7- اگر مشاوره اي در خواست مي گردد بايد حتما گزارش مشاوره با ذکر تاريخ و ساعت در پرونده موجود باشد. گزارشات مشاوره، آزمايشگاه، راديولوژي بايد توسط کسي که آنها را درخواست نموده پاراف گردد. عدم ضمیمه برگ درخواست و جواب آزمایشات

8- مخدوش نبودن مستندات  مخدوش بودن تاریخ ویزیت ، تاریخ اعتبار، تعداد و ساعت وتاریخ مصرف دارو 9- همخوانی و تطابق اطلاعات ثبت شده در برگه های مختلف عدم تطابق در اطلاعات ثبت شده در مورد نوع بیهوشی، فرد بیهوشی دهنده، پایه بیهوشی، زمان و خطر بیهوشی وسن بیمار در برگ شرح عمل و گزارش بیهوشی تناقض در شروع و خاتمه بیهوشی با آغازعمل جراحی عدم تطابق در اطلاعات ثبت شده دربرگه دستورات پزشک، گزارش پرستار و نسخ دارویی 10- کليه دستورهاي شفاهي و تلفني براي درمان بايد توسط پزشك مسئول طي 24 ساعت بعد از دستور باذکر تاريخ و زمان تاييد شوند. نکته : کدگذاری غلط اعمال جراحی، اضافه قیمت در k جراحی، رعایت نکردن مقررات عمومی حرفه ای ، اشتباه در ثبت قیمت دارو و لوام مصرفی توسط تکنسین های دارویی از لحاظ دقت موارد مورد تعهد و عدم تعهد سازمان بیمه در رابطه با دارو می تواند از عوامل دیگر کسورات بیمه های بهداشتی درمانی باشد.

References: CMS, Medicare and Medicaid. Revised June Veteran's Health Care Overview, Available from: Veteran's Health Care Overviewwww.military.com دكتر رضا صفدري، رويا شريفيان مرجان قاضي سعيدي ، دكتر نيلوفر ماسوري، زهرا سادات آزاد منجير، ميزان و علل كسورات اعمال شده به صورتحسابهاي بيمارستانهاي دانشگاه علوم پزشكي تهران، مجله دانشكده پيراپزشكي دانشگاه علوم پزشكي تهران ( پياورد سلامت ) دوره 5 شماره 2 تابستان علي محمدي، امير عباس عزيزي، رامين چراغ بيگي، روح الله محمدي، جواد زارعي، رحمان ستوده، فرشاد فقی سلوک. بررسي ميزان كسورات اعمال شده سازمانهاي بيمه خدمات درماني و تأمين اجتماعي نسبت به صورت حسابهاي ارسالي بيمارستا نهاي آموزشي شهر خرم آباد. طب و تزکیه. تابستان 1392 ، دوره 22 ، شماره 2. حسن باقري ، محمد امیري. بررسی علل کسورات سازمان هاي بیمه گر از اسناد حق العلاج بیماران در یکی از بیمارستان هاي ایران. مدیریت بهداشت و درمان 1391.