Discussion board post INSURANCE REGULATION

Please write 500 word APA paper answering the question below, breaking everything down into elements. Please read the question and below is the instructors’ comments as a go-bye. THE APA FORMAT THAT WE NEED TO YOU FOR THESE ASSIGNMENTS. Please include the ELEMENTS and see the example of the format and a paper already written in that format.

Thank you




This is the question to form the paper/Discussion Board post

Discussion PromptsPA Jones has several patients in the practice with chronic low back pain.  Several have recurrent spasm issues that do not respond to oral muscle relaxants.

Recently, PA Jones attended a conference which advocated for using Botox injections to relieve chronic back spasms.  This seemed like a good idea to use this on patients to see if they get relief.  PA Jones makes the requests to the patient’s insurance company, and submits literature advocating for this treatment.  After a few weeks, four of the five patients receive a denial for this “investigational treatment” citing explicit policies prohibiting coverage for unapproved experimental treatments.  The last insurance is pending, but PA Jones believes they will offer a similar response.

Also, while attempting to purchase the Botox from an approved distributor, the cost is prohibitive.  When discussing this with some colleagues, they offer their “supplier”, who is not an authorized distributor, and obtains it from “somewhere overseas”.  PA Jones proceeds to purchase the vials through this vendor, at a very favorable price.  The vials have a foreign NDC number when they arrive via common carrier, with the shipping manifest indicating “home goods”. 

In the ensuing week, PA Jones brings three patients in for back injections the insurance denied.  After injections, PA Jones submits a bill to the insurance company for Botox migraine scalp injections, although the patients do not have a history of intractable migraines.  The injections went into their back, not their scalp, with the foreign drug product.  The claims go through.  PA Jones also bills for the Botox to insurance using U.S. NDC numbers instead of the foreign unapproved NDC numbers.

A few days later, he receives a call from the local hospital.  Two of his three patients are on ventilators with acute Botulism toxicity.

Answer the following:

1. What is the correct administrative law legal procedure for fighting insurance claims denials?  What is the source of those rules? (Do not just list what some health plan has for rules.  This must come from a source of law).   What sort of cause of action might a patient pursue?

2. What laws regulate the jurisdictional bounds of insurance regulation?

3. What issues present here, and what aspects of this case would be state based, and which might be federal?  Research this carefully.  Find relevant regulations, enumerate the elements, and apply the facts carefully to each element of law in this case, element by element.


Notes from the instructor///


Assignment Information & Instructions

First is the appeals question.  Everything the state/insurance does in appeals (and hence insurance) follows what is called the Administrative Procedures Act (week 1 lecture under Administrative Law).  So outline that appeals process.  There is a federal Administrative Procedures Act and each state has one (they are pretty much identical).


Second, as for jurisdictional bounds, who controls insurance regulations, and WHY? (state vs federal question)


Third, find a couple of relevant laws that apply to the scenario.  Do NOT go down ERISA paths, as that is a black hole.  Some FDA regs like Misbranding would fit nicely if you wanted even though it is only briefly touched upon in the text.  You could easily find 300 applicable laws here.  Do not do that.  Better to fully flesh out two laws, versus throwing 50 at the wall with incomplete analysis and wrong conclusions. 

This is actually how it is done in the real world.  Prosecutors may find 20 potential violations, but you cannot go to a jury with that, expecting them to absorb analysis of all 20.  Each trial would take 2 years.  So prosecutors narrow to the best bang for the time and go with 1-3.  Do the same here.  Fully flesh out a couple and do not get sucked into every law known to man, then don’t list the elements and do incorrect analysis.

Also do not go down the research angle either.  Research drugs are never billed to insurance, so nothing about this fits into “research”.  Informed consent for research is a whole discussion by itself, so it is not necessary to go there since this is not research.



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