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Results for “Insurance Claim Review”

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At least 217 records · Page 12Linked to original sources
PubMed2001

The association between neck pain intensity, physical functioning, depressive symptomatology and time-to-claim-closure after whiplash.

Time-to-claim-closure is a common outcome in cohort studies of whiplash injuries. However, its relationship to health recovery is unknown. We investigated the association between neck pain, physical functioning, depressive symptomatology and time-to-claim-closure in a Saskatchewan cohort of 5398 whiplash claimants in 1994-1995. Participants were surveyed five times over 1 year. In 1995, the insurance system changed from tort to no-fault, eliminating compensation for pain and suffering. Under tort, a 10-point increase in pain reduced the claim-closure rate by 13-24% while a 10-point increase in physical functioning increased it by 17%. Depressive symptomatology reduced the claim-closure rate by 37%. Under no-fault, a 10-point increase in pain reduced the claim-closure rate by 18% while a 10-point increase in physical functioning increased it by 10-35%. The presence of depressive symptomatology reduced the claim-closure rate by 36%. The results suggests lower pain, better function and the absence of depressive symptoms are strongly associated with faster time-to-claim-closure and recovery after whiplash, independent of the insurance system.

Accidents, Traffic↗
PubMed1997

Temporomandibular joint litigation: resolving issues of medical necessity and contract ambiguity.

Courts routinely award coverage for TMJ disorders under medical plans, despite exclusionary language and evidence that the insured failed to disclose preexisting treatment as required by the plan and neglected to attempt more conservative treatment first. Such decisions adversely affect both the health carrier and the plan participants. Various states have enacted legislation mandating coverage of TMJ; however, TMJ issues still exist and will remain a frequent topic for litigation until the judiciary recognizes that validating contract language ultimately benefits insureds as consumers and reinforces the integrity of the industry as a whole.

Humans↗
PubMed2001

A detailed audit of reimbursement for abdominal CT in an academic practice.

RATIONALE AND OBJECTIVES: Declining fee schedules, decreasing operating margins, and increasingly stringent compliance regulations create a need for intense scrutiny and optimization of a radiology organization's billing and collection procedures. The authors' goal was to analyze the effectiveness of departmental professional billing procedures, identify controllable factors, and intervene when they could be improved. MATERIALS AND METHODS: A detailed audit of professional claims and payments was performed for all patients who underwent abdominal-pelvic computed tomography (CT) during July 1999 (n = 717). The adequacy of indication for the CT examination as given by the referring physician and modified by the radiology staff, the time required for claim generation, and the status of reimbursement within 120 days were assessed by an interdisciplinary team. After an intervention was performed to improve adequacy of the available clinical indication, the audit was repeated in December 1999 (n = 710). RESULTS: Despite a significant (P < .05) improvement in wording of clinical indications for billing purposes between July (68%) and December (85%), there was no significant change in reimbursement against gross charges. The vast majority of claims (97% in July, 99% in December) were generated in less than 30 days. At 120 days after the date of service, payments had been received that amounted to only 66% and 54% of discounted professional fees for July and December, respectively. For examinations performed in December, payment was delayed beyond contracted time periods in 138 cases (19%). CONCLUSION: Optimum billing and collection for imaging studies is an increasingly complex task. Even when substantial efforts are devoted to eliciting the proper indication for the study, reimbursement remains low primarily because of payer delays.

Academic Medical Centers↗
PubMed1990

Technology assessment using insurance claims. Example of prostatectomy.

This article describes the findings of an ongoing assessment of prostatectomy that relied on the use of administrative data bases. Examples of the use of claims data for monitoring outcomes and treatment comparisons are provided, as well as a discussion of the strengths and limitations of administrative data for technology assessment.

Aged↗
PubMed1990

Use of insurance claims data in measuring quality of care.

This article discusses data that might be used for measuring quality of care, for health care administrative purposes, and for tracking the use of technologies. The advantages and limitations of administrative data banks for research purposes and some process-of-care and outcome analysis are noted. Three important obstacles to their use--reliability of diagnosis and service information, unique patient identifiers, and provider identifiers--are discussed briefly.

Health Services Research↗
PubMed1990

Impact of claims data research on clinical practice.

Despite their potential utility, clinicians are skeptical about claims data as a substrate for clinical research. Clinician's concerns are centered on two issues-the quality of the data and the fairness of comparisons that are made. To increase the impact of claims data research on clinical practice, several strategies should be pursued.

Humans↗
PubMed1990

Assessment of medical outcomes. New opportunities for achieving a long sought-after objective.

Health outcome assessment may be used for a variety of purposes: to evaluate the effectiveness of medical practices; to assess the quality of services provided; to educate providers, purchasers, and users of health services about the sequelae of treated and untreated disease; to guide reimbursement and regulatory policy; and to characterize the health status of a population. This article focuses on the use of health outcomes to evaluate the effectiveness of medical practices and to assess the quality of services provided.

Health Services Research↗
PubMed2002

Disease burden profiles: an emerging tool for managing managed care.

As health plans assume financial risk for providing health care services, effectively managing the health of a population remains one of the toughest challenges. This article shows how risk assessment methods can be used to measure disease burden in the full population and to discriminate levels of future health care needs within specific disease cohorts. We also examine and compare the predictive power of claims-based models within a diabetic cohort.

Chronic Disease↗
PubMed1999

Object-oriented analysis and design of a health care management information system.

We have created a prototype for a universal object-oriented model of a health care system compatible with the object-oriented approach used in version 3.0 of the HL7 standard for communication messages. A set of three models has been developed: (1) the Object Model describes the hierarchical structure of objects in a system--their identity, relationships, attributes, and operations; (2) the Dynamic Model represents the sequence of operations in time as a collection of state diagrams for object classes in the system; and (3) functional Diagram represents the transformation of data within a system by means of data flow diagrams. Within these models, we have defined major object classes of health care participants and their subclasses, associations, attributes and operators, states, and behavioral scenarios. We have also defined the major processes and subprocesses. The top-down design approach allows use, reuse, and cloning of standard components.

Acute Disease↗
PubMed2003

Return to work and claim duration for workers with long-term mental disabilities: impacts of mental health coverage, fringe benefits, and disability management.

This paper examines the relationship of mental health benefits provided by 116 employers, to return to work and duration of disability claims for 407 of their employees who were on long-term disability (LTD) leave for mental disorders. Mental health benefits data were coded from summary plan description booklets provided by employers. Information on other fringe benefits and employers' disability management practices were obtained from a survey of the employers. Relationships between mental health benefit features, other fringe benefit and disability management factors, and our outcomes were estimated via logistic regression and survival analysis. Results indicated that three mental health benefit plan features were negatively related to the return-to-work probability:(1) a high deductible (> $600), (2) longer preexisting condition exclusion periods, and (3) having a carve-out. This suggests that cost saved by access restrictions may be partially offset by higher turnover costs for employees with disabilities due to mental disorders. Carve-outs were also predictive of shorter claims duration.

Female↗
PubMed2002

State-funded abortions versus deliveries: a comparison of outpatient mental health claims over 4 years.

In this record-based study, rates of 1st-time outpatient mental health treatment for 4 years following an abortion or a birth among women receiving medical assistance through the state of California were compared. After controlling for preexisting psychological difficulties, age, months of eligibility, and the number of pregnancies, the rate of care was 17% higher for the abortion group (n = 14,297) in comparison with the birth group (n = 40,122). Within 90 days after the pregnancy, the abortion group had 63% more claims than the birth group, with the percentages equaling 42%, 30%, and 16% for 180 days, 1 year, and 2 years, respectively. Additional comparisons between the abortion and birth groups were conducted on the basis of claims for specific types of disorders and age.

Abortion, Induced↗
PubMed1991

What should dentists prescribe?

In recent months in Australia the, country's Association has been negotiating with the Federal Government over the rights of dentists to prescribe. The question is not the legal right to order a drug for a patient, but the entitlement of patients to a Government health scheme benefit for the dentist's prescription. The debate has, however, opened up broader questions. What is a reasonable extent of entitlement? What should a dentist be allowed to prescribe?

Australia↗
PubMed2000

Health care, treatment patterns and cost of services for patients infected with chronic hepatitis C virus in a large insured New England population.

The purpose of this study was to describe the cost of health care and the patterns of treatment of young patients (under 65 years of age) identified in health insurance claims as having received services for chronic hepatitis C virus (HCV) infection. We screened computerized claims from a US indemnity and managed care organization for out-patient and in-patient diagnoses related to HCV. Treatment patterns and costs of services were evaluated in the following sites of care: in-patient care, emergency room, hospital out-patient care, ambulatory office care and pharmaceuticals. There were 191 patients with chronic HCV-related claims in this study population (25 per 100 000), during 1995-97. Medical services and pharmaceutical costs in total (US$ 7.1 million) constituted a considerable cost in patients with chronic HCV-related claims during 1995-97. A subset of 98 patients were prescribed interferon-alpha with substantial variability in treatment regimens. Claims data provides a unique opportunity to estimate dollars paid for treatment patterns and health services in a 'real world' insured population and contributes to the understanding of health services for chronic HCV.

Adult↗