This document discusses financial aspects of genetic testing. It provides an overview and agenda covering topics like navigation of the payment process, improperly insured patients, sponsored testing, and challenges like fake labs, lack of CPT codes, and duty to recontact. The objectives are to understand the appeal process, ways to improve approval chances, and ethical issues around duty to recontact. It outlines steps for claims, medical review, and appeals and provides tips on managing secondary insurance, over/under-insured patients, and sponsored testing programs. Problems discussed include fake labs billing fraudulently, lack of specific CPT codes for some tests, and uncertainty around who is responsible for recontacting patients about updated genetic results.
A teaching aid on addressing hesitancy to Covid-19 vaccination. WHO has identified vaccine hesitancy as a major threat to global health. Learn more about how to work with patients, the public and communities to improve confidence in Covid-19 vaccines.
COVID 19 Team-Based Approaches to Patient PopulationsCHC Connecticut
As presented as part of The Path Forward on Jan 28, 2021:
Stable housing and health outcomes are inextricably linked. When a patient loses housing – or is in jeopardy of losing housing– health outcomes suffer. COVID has led us to a moment of crisis. Thirty million to 40 million people in the United States face eviction. People of color are disproportionately impacted. Addressing housing as a social determinant of health is critical to achieving health equity. This webinar brings together experts from housing, healthcare and the intersection of both to share innovative short- and long-term solutions you can implement in your community.
A teaching aid on addressing hesitancy to Covid-19 vaccination. WHO has identified vaccine hesitancy as a major threat to global health. Learn more about how to work with patients, the public and communities to improve confidence in Covid-19 vaccines.
COVID 19 Team-Based Approaches to Patient PopulationsCHC Connecticut
As presented as part of The Path Forward on Jan 28, 2021:
Stable housing and health outcomes are inextricably linked. When a patient loses housing – or is in jeopardy of losing housing– health outcomes suffer. COVID has led us to a moment of crisis. Thirty million to 40 million people in the United States face eviction. People of color are disproportionately impacted. Addressing housing as a social determinant of health is critical to achieving health equity. This webinar brings together experts from housing, healthcare and the intersection of both to share innovative short- and long-term solutions you can implement in your community.
The UN has requested Member States to include UN personnel in the national/host country COVID-19 vaccination
programmes. While confirming the inclusion of UN personnel within their national planning, most Member States
have advised that they will be providing the vaccine free of charge. The vaccine may also be available and
accessed through a primary care provider, and in many cases that cost will be covered by medical insurance.
In countries where there is no national programme in place, or in which UN personnel are not included in the
national distribution programme, the UN Department of Operational Support (DOS) has been tasked by the
Secretary-General to identify alternative arrangements for making the vaccine available. DOS is working to ensure
alternative arrangements are put in place for UN personnel.
Member States have also been requested by the Secretary-General to follow the WHO’s Values Framework and
Prioritization Roadmap for the fair and equitable allocation and prioritization of the COVID-19 vaccine.
Health insurance is one of the most complex products consumers will ever purchase. Starting October 1st, 2013, new health insurance marketplaces in many states will begin open enrollment for individuals, families and small businesses. Learn about what is being done to ensure consumers are fully informed and understand how to get the coverage they need.
Kathy Paez from the American Institutes of Research (AIR) will share the results from a national representative survey of consumer’s health insurance literacy. Coming at this historic juncture, AIR’s applied research offers insights in tailoring outreach and communication messages to consumers trying to understand health insurance in the new state and federal marketplaces.
Also presenting will be Jennifer Messenger Heilbronner from the Metropolitan Group. Jennifer will bring an insider’s view into strategies being used by Cover Oregon. As a new state insurance marketplace, her team is tasked with reaching a wide variety of audiences, addressing misperceptions and getting uninsured people in her state covered.
This resource was from the fourth session in the CALPACT sponsored Health Communication Matters Webinar Series, which will help participants in all walks of public health to apply health literacy principles to their everyday communications.
Please visit here to listen to the audio recording of the webinar:
https://cc.readytalk.com/play?id=551ax7
Visit these links for the other resources related to this webinar:
Health Literacy Undervalued by Public Health? A tool for public health professionals:
http://www.slideshare.net/SPHCalpact/calpact-training-health-literacy-undervalued-by-public-health-training-tool
Applying Health Literacy to Health Insurance - Resources
http://www.slideshare.net/SPHCalpact/applying-health-literacy-to-health-insurance-resources
Follow Us on Twitter: @CALPACT
Facebook: http://www.facebook.com/CALPACTUCB
Website: www.calpact.org
Questions?
Email sphcalpact@berkeley.edu
The UN has requested Member States to include UN personnel in the national/host country COVID-19 vaccination
programmes. While confirming the inclusion of UN personnel within their national planning, most Member States
have advised that they will be providing the vaccine free of charge. The vaccine may also be available and
accessed through a primary care provider, and in many cases that cost will be covered by medical insurance.
In countries where there is no national programme in place, or in which UN personnel are not included in the
national distribution programme, the UN Department of Operational Support (DOS) has been tasked by the
Secretary-General to identify alternative arrangements for making the vaccine available. DOS is working to ensure
alternative arrangements are put in place for UN personnel.
Member States have also been requested by the Secretary-General to follow the WHO’s Values Framework and
Prioritization Roadmap for the fair and equitable allocation and prioritization of the COVID-19 vaccine.
Health insurance is one of the most complex products consumers will ever purchase. Starting October 1st, 2013, new health insurance marketplaces in many states will begin open enrollment for individuals, families and small businesses. Learn about what is being done to ensure consumers are fully informed and understand how to get the coverage they need.
Kathy Paez from the American Institutes of Research (AIR) will share the results from a national representative survey of consumer’s health insurance literacy. Coming at this historic juncture, AIR’s applied research offers insights in tailoring outreach and communication messages to consumers trying to understand health insurance in the new state and federal marketplaces.
Also presenting will be Jennifer Messenger Heilbronner from the Metropolitan Group. Jennifer will bring an insider’s view into strategies being used by Cover Oregon. As a new state insurance marketplace, her team is tasked with reaching a wide variety of audiences, addressing misperceptions and getting uninsured people in her state covered.
This resource was from the fourth session in the CALPACT sponsored Health Communication Matters Webinar Series, which will help participants in all walks of public health to apply health literacy principles to their everyday communications.
Please visit here to listen to the audio recording of the webinar:
https://cc.readytalk.com/play?id=551ax7
Visit these links for the other resources related to this webinar:
Health Literacy Undervalued by Public Health? A tool for public health professionals:
http://www.slideshare.net/SPHCalpact/calpact-training-health-literacy-undervalued-by-public-health-training-tool
Applying Health Literacy to Health Insurance - Resources
http://www.slideshare.net/SPHCalpact/applying-health-literacy-to-health-insurance-resources
Follow Us on Twitter: @CALPACT
Facebook: http://www.facebook.com/CALPACTUCB
Website: www.calpact.org
Questions?
Email sphcalpact@berkeley.edu
State Reform Survey Workgroup Meeting, February 2015soder145
A year has passed since full ACA implementation, and several states are gearing up for data collection in 2015. To guide this process and generate ideas, SHADAC is convened a web-assisted conference call. Colorado and Oregon shared their experiences selecting new reform-relevant content for their surveys, and researchers from the Urban Institute shared lessons learned from the Health Reform Monitoring Survey (HRMS).
Justice or Just Us: Understanding Bias and Managing Health Professional Lice...Harry Nelson
Presentation to the National Medical Association on the issue of bias in Medical Board and other health professional licensing and enforcement and recommendations for preventing and managing investigations.
If you or a loved one has been a victim of medical malpractice that has caused you harm or injury, you may be entitled to medical malpractice recovery. To file a medical malpractice case, you need to contact a medical malpractice lawyer, the concerned medical professional and medical licensing board. If you need help filing a medical malpractice claim, call 203-445-6542 or email george@ganiminjurylawyers.com
website: http://www.ganiminjurylawyers.com
Ken Burgess, Matt Fisher and David Broyles present to the Association of Home & Hospice Care on Alternative Sanctions and Minimizing the Impact on Your Agency
The COVID-19 pandemic has created several challenges for our country’s health care infrastructure, and the community health center workforce is no exception. Join us as we describe strategies to get patients back into dental care. Along with these strategies, participants will learn how to recognize challenges in dental practices, as well as how to engage the interdisciplinary care team through role redesign and integration to increase access to comprehensive care.
NTTAP Webinar Series - June 7, 2023: Integrating HIV Care into Training and E...CHC Connecticut
In order for health centers to provide compassionate and respectful HIV prevention, care, and treatment in comprehensive primary care settings, the clinical workforce must be knowledgeable, confident, and competent in their ability to do so.
We’ll explore the need to integrate HIV care into training and education for the clinical care team, as well as educational models to train the next generation. Using Community Health Center Inc.’s Center for Key Populations Fellowship for Nurse Practitioners (NPs) as a framework for best practices, experts will discuss how to implement specialty care for key populations in your training programs. Additionally, participants will gain awareness of the importance of training the clinical workforce on key population competencies in HIV programs (e.g. HCV, MOUD, LGBTQI+ health, homelessness, and harm reduction).
Utilizing the Readiness to Train Assessment Tool (RTAT™) To Assess Your Capac...CHC Connecticut
Improve educational training experiences at your health center by assessing your capacity and infrastructure to host health professions students.
Join the upcoming hands-on interactive activity session to learn how to utilize the Readiness to Train Assessment Tool (RTAT™). This tool was developed by HRSA-funded National Training and Technical Assistance Partners (NTTAP) at Community Health Center, Inc. (CHC) to understand organizational readiness to host health professions student training programs.
NTTAP Webinar Series - May 18, 2023: The Changing Landscape of Behavioral Hea...CHC Connecticut
The COVID-19 pandemic has resulted in significant shifts in the mode of care from face-to-face to virtual interactions. Join us as we discuss the challenges currently facing behavioral health care and at least one strategy for each. Along with these strategies, panelists will go over what integrated behavioral health care was and is before and following COVID-19, as well as what actions should be taken going forward to increase access to comprehensive care.
Panelists:
• Dr. Tim Kearney, PhD, Chief Behavioral Health Officer, Community Health Center, Inc.
• Melinda Gladden, LCSW, PMHC, Behavioral Health Clinician, Community Health Center, Inc.
• Jodi Anderson, LMFT, Virtual Telehealth Group Coordinator, Community Health Center, Inc.
NTTAP Webinar Series - April 13, 2023: Quality Improvement Strategies in a Te...CHC Connecticut
Join us for a webinar on quality improvement in team-based care!
Building a quality improvement (QI) infrastructure within team-based care is an organizational strategy that will establish a culture of continuous improvement across departments and improve quality in all domains of performance.
Participants will learn about:
• QI infrastructure
• Facilitating QI committees
• Coach training within health centers
Faculty will also provide an example of how trained coaches use QI tools to test and implement changes within an organization.
Implementation of Timely and Effective Transitional Care Management ProcessesCHC Connecticut
Join us to discuss best practices for integrating daily follow-ups for patients recently hospitalized for health emergencies. Effectively following up with patients is a critical responsibility for integrated care teams.
Experts will share how their teams respond to patients to identify care gaps and support the transition of care. Workflow descriptions will provide participants with the tools to support their work to adapt specific steps into their model of team-based care.
Panelists:
• Mary Blankson, DNP, APRN, FNP-C, FAAN, Chief Nursing Officer, Community Health Center, Inc.
• Veena Channamsetty, MD, FAAFP, Chief Medical Officer, Community Health Center, Inc.
• Bibian Ladino-Davis, Behavioral Health Coordinator, Weitzman Institute
Implement Behavioral Health Training Programs to Address a Crucial National S...CHC Connecticut
Health centers are uniquely positioned to address the unprecedented need for behavioral health services but are challenged by the workforce shortage. Participants will gain the knowledge needed to begin conceptualization of a training pathway.
Join us to discuss the considerations of sponsoring an in-house training program across all educational levels, including the benefits, program structure, design, curriculum, supervisors' role, and required resources.
Experts will provide participants with examples from practicum and postdoctoral level training programs to help them gain confidence in developing a behavioral health training pathway.
HIV Prevention: Combating PrEP Implementation ChallengesCHC Connecticut
Expert faculty present case-based scenarios illustrating common challenges to integrating HIV PrEP in primary care. As part of improving clinical workforce development, this session will delve into a variety of specific PrEP implementation challenges. Participants will leave with strategies to overcome these obstacles to establish or strengthen their PrEP program.
Panelists:
• Marwan Haddad, MD, MPH, AAHIVS, Medical Director, Center for Key Populations, Community Health Center, Inc.,
• Jeannie McIntosh, APRN, FNP-C, AAHIVS, Family Nurse Practitioner, Center for Key Populations, Community Health Center, Inc.
NTTAP Webinar Series - December 7, 2022: Advancing Team-Based Care: Enhancing...CHC Connecticut
Join us as expert faculty outline the differences between case management, care coordination and complex care management to frame up a discussion on strategies to leverage effective models for both in-person and remote services.
Expert faculty will discuss the role of the medical assistant and the nurse in care management, as well as how standing orders and delegated orders support this work. This session will discuss how telehealth and remote patient monitoring enhancements can support complex care management for patients with chronic conditions.
Participants will leave this session with the knowledge and tools to begin or enhance implementation of chronic care management by enhancing the role of the medical assistant, nurse and the technology that supports the clinical care.
Panelists:
• Mary Blankson, DNP, APRN, FNP-C, Chief Nursing Officer, Community Health Center, Inc.
• Tierney Giannotti, MPA, Senior Program Manager, Population Health, Community Health Center Inc.
NTTAP Webinar: Postgraduate NP/PA Residency: Discussing your Key Program Staf...CHC Connecticut
Expert faculty will discuss the drivers, benefits, and processes of implementing a postgraduate residency training program at your health center. This session will dive deeper into a discussion on the responsibilities of key program staff, preceptors, mentors, and faculty for successful implementation. This webinar will equip participants with a road map to go from planning to implementation and offer an opportunity for coaching support.
Panelists:
• Program Director of the Nurse Practitioner Residency Program, Charise Corsino, MA
• Clinical Program Director of the Nurse Practitioner Residency Program, Nicole Seagriff, DNP, APRN, FNP-BC
Training the Next Generation within Primary CareCHC Connecticut
This webinar discussed the various avenues of workforce development including:
• training non-clinical roles
• the value of an administrative fellowship
• the key questions to ask before establishing a fellowship at your agency
The discussion referenced CHC Chief Operating Officer Meredith Johnson and CHC Project Manager Megan Coffinbargar’s publication “Establishing an Administrative Fellowship Program: A Practical Toolkit to Support and Develop Future Community Health Center Leaders” for the National Association of Community Health Centers (NACHC).
Panelists:
• April Joy Damian, PhD, MSc, CHPM, PMP, Vice President and Director of the Weitzman Institute, Community Health Center, Inc.
• Megan Coffinbargar, MHA, Project Manager, Optimizing Virtual Care Initiative, Community Health Center, Inc.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
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We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Financial Aspects of Genetic Testing - 1/11/22
1. Financial Aspects of Genetic
Testing
Matt Fickie, MD, FACMGG
Senior Medical Director
Highmark, Inc.
January 11th, 2021
1
2. Objectives
By the end of this session, attendees will be able to:
Objective 1: List the steps in the appeal process
Objective 2: Understand ways a practitioner can improve their chances of
approval
Objective 3: Examine the ethical issues involved in Duty to Recontact
2
3. “Levelsetting”
Levelsetting- v. business word stated at the outset of all meetings
to help remind you why you’re there.
This talk bridges 2 topics:
• Genetics
• Coding
4. Agenda
Overview
Topic 1- Navigation
Topic 2- Improperly Insured
Topic 3- Sponsored Testing
Topic 4- Why is this so hard?
Topic 5- Duty to Recontact
Problems in Genetic Testing &
Payors
Problem 1- Fake Labs
Problem 2-Lack of CPT Codes
Problem 3-Duty to Recontact
5. Navigation
What are the steps required to pay for a service?
Three Pathways:
– Pre-determination
• The weakest guarantee
– Prior authorization
– Submitting a claim
6. Step 1: Claims
1. Verification of Demographics
– Wrong company?
2. Verification of Benefits
– Does the member have this
service covered?
3. Verification of all Responsibility
– Subrogation
– Are we primary or
secondary?
4. Pre-pay edits
– Approve
– Deny
– Pend for Review
7. What is a Pre-Pay
Edit?
• A way to deny or approve
a request based on fully
automated criteria
• If test 0026U is
investigational, I can deny
it with no other
information
• Do you have a prior claim
for whole-genome
sequencing? Denied.
8. Step 2: Medical Review
The process varies by company, but the structure is basically the
same
• Step 1 - In-house review
– Peer-to-peer*
• Step 2 – Appeal
• Step 3 - Appeal to either same-specialty reviewer or an IRO
(Independent Review Organization)
– Ask the person on the phone what’s available
*If you appeal before a peer to peer, you
lose that peer to peer
9. Step 3: Peer-to Peer
Please be nice!
• When discussing a case with a Medical Director, you can argue
either the policy or that a test is medically necessary.
– Medical Policy Criteria
Usually, you can Google the company’s name and the test you’re looking for
must be publicly available
10. Definition of Medical Necessity
• Every payer has one. This helps frame the meaning of every
interaction we have.
– All are stolen from Medicare
• Medicare’s definition of medical necessity
– Health-care services or supplies needed to prevent, diagnose or treat
an illness, injury, condition, disease or its symptoms and that meet
accepted standards of medicine.
11. Step 4: Appeals
• There is no formal difference in review between an initial
request and an appeal
– But most Medical Directors will give an appeal more scrutiny
• Letters of Medical Necessity can help
– Not when they are clearly from the lab
– Not when they are 10 pages long
– Not when they are antagonistic
12. Clinical Notes
Good Example
I saw _____today for depression follow-
up. Still recalcitrant.
– SLE
Continue MTX
– Depression
Continue Zoloft + Abilify
Check PGx
Bad Example
I saw ____today for a routine physical
exam. He was counseled about prostate
cancer risk.
– SLE
Cont. MTx
Cont. Zoloft +Abilify
Check PGx
13. Knowledge Claims
• Why is everything Investigational/Experimental?
– Payors use different sources of information for decision making
– CMS is important
– Health Technology Assessment companies are subscribed to
– Evidence-based guidelines (not consensus guidelines)
15. The Over/Under-Insured
• What is an “Underinsured” situation?
– High-deductible plan sold to someone who can’t pay the deductible
– Most state Medicaid plans- smaller pie to slice
– “Grandfathered” plans- weak plans which were in effect prior to
ObamaCare & “Grandfathered”
• These are rare but Trump allowed sale of short-term products
– Good insurance sold to someone who can’t navigate it*
*Vast majority of US population
16. Workarounds for Under-Insured Patients
• High-deductible plans – wait until the end of the year
• Grandfathered plans or plans without a genetic testing benefit
(extremely rare) – give up
• Medicaid - Adjust your expectations. They won’t pay for WGS,
which might be cheaper in the long run, but take the
microarray and argue for a panel
17. Workarounds for Well-Insured Patients
• Perform a P2P
– This is the best way to 1) get your test approved and 2) avoids
having your patient act
• Take over the patient’s appeal rights
– Your legal department should have a template
• Know your regions primary insurers in-network labs
– Painful but if you know to send Myriad to Cigna and Ambry to
Aetna, then your approval rates will be higher
18. Secondary Insurance
Secondary insurance should cover costs one’s primary insurance does
not.
Common Examples:
– Primary private insurance (UHC) with secondary Medicaid for a child with
severe neurologic injury who has a parent who works
– Primary private insurance (Highmark) with secondary Medicare A
(hospitalization) for a person on dialysis who works
– Primary Medicare with Medicaid secondary – common for disabled
persons with lower incomes
19. Managing Secondary Insurance
The best way: submit all co-pays to the secondary to decrease
out-of-pocket costs
Pitfalls:
– A provider submits to the secondary first
– The primary does not approve a particular service. Then there is
controversy between the policies on whether the secondary will pay
if the claim meets their criteria. Chaos ensues.
20. What about the Over-Insured?
• Why did Obama try to get rid of “Platinum Plans?”
– Having too much insurance leads to moral hazard
– The over-insured are more likely to over-access healthcare
– Plans which require reasonable co-pays, co-insurance and/or
deductibles do not diminish healthcare uptake
Brook, Robert H., Emmett B. Keeler, Kathleen N. Lohr, Joseph P. Newhouse, John E. Ware, William
H. Rogers, Allyson Ross Davies, Cathy D. Sherbourne, George A. Goldberg, Patricia Camp, Caren
Kamberg, Arleen Leibowitz, Joan Keesey, and David Reboussin, The Health Insurance Experiment:
A Classic RAND Study Speaks to the Current Health Care Reform Debate. Santa Monica, CA: RAND
Corporation, 2006. https://www.rand.org/pubs/research_briefs/RB9174.ht
21. Topic 3: Sponsored Testing
For years, the BIG LABS have made offers to patients & doctors:
Send your sample to us and we will cap your out-of-pocket
payment to $100.
– I used these all the time when I was practicing
Here’s the problem
– This incentivizes people to use a lab which the payor doesn’t want
you to use and sometimes there’s a reason for that*
*See Fake Labs, forthcoming
22. Problem #1: Fake Labs
• Over $1 Billion was billed
through fake labs in 2018
• Some are vacant shops in strip
malls
– Either have or steal a CLIA
number & provider ID
• At Highmark, we found one!
• We cover roughly 6.5M people
– We processed 108M claims last
year
– Finding the fraudster is very
difficult
23. Problems in Genetic Testing
• Fake Labs
• Lack of CPT Codes
• Duty to Recontact
25. Case: Lack of CPT Codes
• Bill: orders a craniosynostosis panel
through BIG LAB – East with United
Healthcare, and it’s approved
• Sam: orders the nearly identical panel
using BIG LAB – West with United
Healthcare, and it’s denied
26. What Happened?
BIG LAB – East: 18 genes
• CPT: 81402 – approved
– Tier 2 code representing a small-to-
medium panel
BIG LAB – West: 20 genes
• CPT: 81402 – approved
• CPT: 81479
– The unspecified code is billed
legitimately for additional del/dup
analysis for which there is no other
code
– Because 81479was denied, the lab
called the provider and stated that
the test was denied (insufficient
reimbursement)
27. Alternate Endings
The test above could have been denied because:
• Different UHC Plans
• Lack of clinical information
• Medical Director’s lack of genetics knowledge
• Out-of-Network testing available In-Network
– Rare to deny this; more likely a high co-pay then the member tells the lab “no”
28. Lack of CPT Codes
Huge problem in genetics
# possible disease panels X # of labs = size of the problem
AMA invented Proprietary Laboratory Analysis (PLA) codes which
labs can apply for to identify their tests separately
4 numbers then a U, e.g. 0027U
AMA just held a meeting which identified problems, no solutions
See Resources for link to AMA
document
29. Duty to Recontact
The question is: whose job is it to update genetic testing results?
Especially whole genome sequencing
We know we don’t know everything about genomics
How do we let someone with a “maybe” change in a cancer gene
(BRCA1) know when their change is upgraded to “yes, you have
the disease” change?
30. Duty to Recontact
Suspects for Accountability
The doctor ordering the test
The laboratory performing the
test
The person/patient/member
The insurance company
Concerns
Who has a longitudinal relationship?
Who has a legal responsibility for the
test?
Who has a moral responsibility?
What about the pragmatic issue of finding
someone?
31. Duty to Recontact
Issue is not resolved; no one wants responsibility
Labs have built various ways to curate information & receive
updates
Everyone remains at a basic disadvantage when a patient moves
The average American changes insurance about every 2 years
32. Lab Insecurity
• Hopefully, at this point I’ve
– Improved the status of insurance companies in your hearts
– Shown how Good genetic testing gets swept up with Bad testing (or
coding & billing)
– Demonstrated competing interests between provider, payor, and
laboratory
– Explained that not everyone is acting in good faith all the time ;lbjk
33. TipSheet
Easy Do’s
Look at the medical policies of your most
frequent payors
Lots of Peer-to-peers
Letter of Medical Necessity
Or
Attach clinic notes & clinical guidelines
Easy Don’ts
Try to memorize details of a
particular plan
Be difficult during peer-to-peers
Letter of Medical Necessity
Include primary literature,
especially case reports unless
your request is a Hail Mary