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PubMed2002

Improving office operations and maximizing reimbursement for the orthopedic practice.

After assessing the efficiency of the medical/surgical practice, the physician should work on implementing goals with the practice manager or administrator. To assist in the implementation of these goals, the physician should be involved in strategic planning. By taking each project one step at a time, and through better communication and practice efficiency, a medical office can survive in today's managed care and complex health care environment.

Financial Management↗
PubMed2002

Coding and billing for gastrointestinal endoscopy.

The complexities associated with the coding, billing, and reimbursement process seem to increase daily. Keeping abreast of the changes in this environment is, to say the least, a challenge. To succeed in today's billing environment the gastroenterologist should surround his or her practice with staff, resources, and education. Experienced skilled staff, preferably a certified professional coder should be employed. Certified coders bring advanced coding skills to ones practice, which allows increased proficiency with the coding and billing process. Provide the necessary resources for staff. Current coding material is crucial to the financial success of the practice. CPT-4, ICD-9, and Correct Coding Guide are the bare basics of the resource material available to staff. Maintaining a library of resource material (i.e., Medicare bulletins, managed care newsletters, and so forth) aids the staff with the necessary tools to carry out their duties. In addition, specific gastroenterology coding subscriptions are available to assist in staying ahead of the ever-changing billing and coding environment. Continuing education in the billing and coding process for both the physician and staff is essential. Numerous workshops are offered periodically. It is imperative that staff attends all Medicare-sponsored workshops in addition to gastroenterology-specific coding seminars. More and more physicians are now aware of their responsibility in the billing process and have begun to participate in the coding education along with their staff. This is a significant indicator of a physicians' intent to have a compliant and financially successful practice.

Cost-Benefit Analysis↗
PubMed1994

Combining benchmarking with other quality tools to achieve breakthroughs in admitting.

BACKGROUND: A cross-industry benchmarking study in which St Joseph's Regional Health Systems participated recommended that the admissions process (that is, preverifying insurance, obtaining demographic information) be completed before patients arrive at the hospital. To apply this best practice at St Joseph's, management established three team efforts. IMPROVING PREVERIFICATION. One team was assigned to improve the insurance preverification process. After cross-training staff to carry out preverification and piloting a electronic, on-line preverification system, the team increased St Joseph's preverification rate from 2% to 70% for scheduled patients. EXPLORING SEAMLESS REGISTRATION: After exploring solutions for an on-line system that will be integrated across the St Joseph system, the team recommended expanding the current computer system to include all entities and to integrate demographic and clinical information. In addition, a subteam reduced the number of registration forms patients must fill out from eight to one. REDESIGNING ADMISSIONS/REGISTRATION. As part of its restructuring effort, St Joseph's is redesigning six core processes, including admissions/registration. This redesign team is currently implementing two recommendations from the benchmarking study: express admitting and centralized scheduling. LESSONS LEARNED: Organizations are advised to understand the process in its current state by collecting data and working toward improvement goals--and to be prepared for changes in job functions and allocation of resources. Other recommendations are offered to organizations attempting to apply best practices from a benchmarking study.

Admitting Department, Hospital↗
PubMed1997

Basic insurance concepts for dentists.

Dentists cannot afford to be ignorant about insurance. Insurance is an important risk-management tool, minimizing the exposure for catastrophic claims and losses. Patient insurance is also a major source of revenue for most dental practices.

Insurance↗
PubMed1998

Dental negligence: a study of cases assessed at one specialised advisory practice.

AIM: To undertake a review of cases from one dental advisory practice in England over a period of 5.5 years to provide a profile of the type of work undertaken. DESIGN AND SETTING: Compensation claims for dental negligence seen at one dental advisory practice between 1991 and 1996. METHODS: 437 claims were reviewed for: the nature of the complaint; defendant details; plaintiff details; method of funding; duration and outcome of claim. Comparisons were made with previously published data. The relationship between method of funding of a claim and the likelihood of the claim being successful was investigated. RESULTS: 28% of complaints concerned oral surgery and 24%, restorative procedures. In 72% of cases, the compensation claim was made directly against the dentist who had provided treatment for the patient. The majority of claims were gender and age biased; females (63%) and younger people (18-45 years of age) (68%) were more likely to bring actions for dental negligence. Only 3% involved elderly patients (> or = 60 years old). Claims supported by the government legal aid scheme were more likely to be withdrawn or rejected than those privately funded. Nearly all cases were completed in under one year (81%). CONCLUSIONS: Results are similar to previously published studies. A large proportion of claims concerned restorative or oral surgery procedures carried out in general or community practice.

Adolescent↗
PubMed1982

Medicare's nursing-home benefit: variations in interpretation.

The use of skilled-nursing facilities by Medicare beneficiaries as measured in days of care per thousand elderly persons varies considerably from one state to another. To explore the possibility that this variation reflects differences in the administrative interpretation of rules governing coverage, we developed nine hypothetical cases and presented them by telephone to claims reviewers in fiscal intermediaries and professional standards review organizations. Cases were designed to illuminate the reviewers' use of discretion. We observed marked differences both in the reviewers' decisions to cover or not cover patients and in the reasoning behind their decisions. Three of the 18 reviewers decided to cover very few cases; almost half the reviewers decided to cover most of the cases, but not the same ones. In only two cases did the 18 reviewers approach consensus. This variation is a reflection of the complexity of Medicare's coverage rules and its decentralized administration. To reduce variation, we recommend more centralized review with oversight by Medicare's central office rather than by its 10 regional offices. This oversight should include the training of reviewers in a way that focuses on complex cases to improve the consistency of judgment.

Eligibility Determination↗
PubMed1990

Universal New York Health Care. A single-payer strategy linking cost control and universal access.

Now that universal access to health care is back on the governmental agenda, elected officials are faced with the dilemma of expanding our present pluralistic system of numerous private and public payers, with its built-in administrative inefficiencies and inflationary pressures, or scrapping the present system of financing and moving to a tax-based scheme like the Canadian Medicare program, an option fraught with political difficulties. There is, however, a third option. The New York State Department of Health has developed a proposal for universal access--Universal New York Health Care, or UNY-Care--that would retain the existing payers, including employer-based insurance coverage, but combine them in a one-payer framework. Providers would no longer have to interact with the many public and private payers, each with its own rules, criteria, and levels of payment. The single payer would serve as the only payer for most health care services and would also negotiate reimbursement rates. The single-payer framework should bring savings in administrative and billing costs and should move government closer to the goal of buying health care services--getting good value for payment rendered--rather than simply paying bills as they are submitted. Although the single-payer strategy could be implemented at either the state or the federal level, it seems ideal as the principal responsibility of the states in a national plan for universal coverage.

Cost Control↗
PubMed2002

The risk of hospitalization in patients with asthma switched from an inhaled corticosteroid to a leukotriene receptor antagonist.

Asthma-related hospitalization rates were compared over a 2-year period between a cohort of patients with asthma who switched from an inhaled corticosteroid in year 1 to a leukotriene modifier in year 2 (n = 285) and a matched cohort continuously treated with an inhaled corticosteroid (n = 570). During year 1, patients were well maintained, with a hospitalization rate of 1.1% to 1.4%. During year 2, 2.5% of the patients switched to a leukotriene modifier had one or more asthma-related hospitalizations compared with 0.6% of the patients continuously receiving an inhaled corticosteroid. Patients treated with a leukotriene modifier were at 7 times greater risk for an asthma-related hospitalization compared with patients who continued to receive an inhaled corticosteroid (risk-adjusted odds ratio, 7.1; 95% CI, 2.79-17.95). These data are consistent with the results of well-controlled clinical trials showing that leukotriene modifiers may be associated with deterioration of asthma control relative to inhaled corticosteroids. Considered in aggregate, the data support the conclusion that leukotriene modifiers should not be substituted for inhaled corticosteroids as a single-controller therapy for asthma.

Administration, Inhalation↗
PubMed1990

Trilogy of the "Triad of O'Donoghue" in the knee and its analogy to the TMJ derangement.

An attempt has been made to describe the similarities between the pathological injury "Triad of O'Donoghue" in the knee and its analogous equivalent in the internal derangements of the temporomandibular joint (internal derangements). Because of the similarities between these internal derangements and the treatment they require, TM joint internal derangements should be reimbursed as a medical problem by insurance carriers as internal derangements in the knee are reimbursed. A description of the anatomical, physiological, and arthro-kinomatics of these two synovial joints has been done to further point out that they both operate by the same physiological principles, and therefore should be treated as similar dysfunctions. Treatment should be rendered to the TM joint, as in the knee, from an orthopedic viewpoint. This requires that treatment to the TM joint include a cooperative rehabilitative team approach. This team approach encompasses medical and dental cooperative care to stabilize the joint and secondarily control joint related soft tissue compensation and pain.

Abstracting and Indexing↗