How should health plans balance interests of their enrollees

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Reference no: EM131656435

A 78-year-old male with a history of chronic comorbidities that include hypertension, diabetes, hyperlipidemia, and coronary artery disease presents with a warm, swollen, tender, left arm. He saw his primary care physician 2 days ago, at which time he was prescribed oral penicillin.

Upon being triaged at the emergency department, he is found to be febrile with a temperature of 103 degrees. His right arm has an 8 cm x 12 cm area of erythema and sclerosis, which is tender to the touch. There is moderate weeping of serosanguinous fluid from the posterior aspect of the arm.

The patient is admitted with a diagnosis of severe sepsis and immediately started on intravenous Flucloxacillin 2g IV QDS + Clindamycin 1.2g IV QDS + Gentamicin 7mg/kg IV. He also requires intravenous cyclo-oxygenase-2 with oxycodone.

On the third day of being of hospitalized, the patient's health plan utilization management nurse stops by to check on him. She asks how he is feeling and he tells her he is feeling better than the past few days. Upon check up, he is afebrile, and the sepsis area has decreased by 40%. However, he is still not able to tolerate a diet other than clear liquids, and is ambulating with assistance.

The patient’s PPO health plan notifies the hospital that effective this day, the health plan has determined that further inpatient care is no longer medically necessary and, as such, payment for services beyond this day will be denied.

The patient’s attending physician calls the health plan medical director to advocate for his patient. He explains that the the patient requires further hospitalization because this is the first day he has shown some improvement but he is not fully recovered. The physician explains to the medical director that the patient lives alone which would make it difficult for him to care for himself because he is not able to ambulate without assistance. The medical director responds that based on the information collected during rounding by the utilization management nurse, the patient is stable and ready to be discharged; he may be followed up as an outpatient. The call ends without any resolution.

Questions :

What responsibility does a physician have to advocate for his/her patient?

What factors can limit a physician's ability to advocate for his/her patient?

What obligation, if any, does a health plan have to find a mutually acceptable solution to provide the care requested by the physician?

How should health plans balance the interests of their enrollees?

What recourse does a physician have if his treatment plan is denied by the health plan?

Reference no: EM131656435

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