规定的最低福利投诉:五年后回顾性审查
Lindelwa Mitchele Ngobeni1, Lucky Moropeng2, Evelyn Thsehla3
1Schools of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria. lindelwamn@gmail.com.
概括
医疗计划会员经常抱怨规定最低福利 (PMB),特别是在慢性疾病. 大多数拒绝来自开放计划,突出需要更好的成员教育和更清晰的PMB定义.
科学领域:
- 医疗保健服务研究 医疗服务研究
- 公共卫生 公共卫生
- 卫生政策分析 卫生政策分析
背景情况:
- 医疗计划法要求所有医疗计划会员获得规定的最低福利 (PMB).
- 医疗计划受益人可以向医疗计划委员会 (CMS) 报告索赔拒绝情况.
研究的目的:
- 分析2014年至2018年期间医学计划委员会 (CMS) 收到的规定最低福利 (PMB) 投诉的模式.
主要方法:
- 一项横截面研究分析了CMS的临床投诉数据.
- 数据提取包括PMB,投诉人详细信息,计划类型和拒绝原因.
- 分析使用SAS v.9.4软件,将计划分类为开放或受限制的.
主要成果:
- 分析了1124起PMB的投诉,平均每年225起投诉.
- 非传染性疾病 (NCD) 是投诉中引用的最常见的PMB疾病.
- 医疗和外科服务面临最频繁的支付拒绝,主要来自开放的医疗计划.
结论:
- 慢性疾病是医疗计划成员在PMB方面关注的重要领域.
- 加强会员教育和更明确的PMB定义对于医疗计划和CMS的解决方案至关重要.
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