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PubMed2000

Medical care program compliance--a year 2000 recipient perspective of Medicare claims.

This article provides a brief assessment of patient and provider views and concerns regarding reimbursements under the Medicare program. Specifically targeted is the payment of pharmaceutical claims. Also addressed are the ongoing and respective responsibilities of individual clinical providers, associated hospitals, and recipients of care. A summation of significant results of direct interviews and follow-up discussions with 10 Medicare recipients also is provided.

Aged↗
PubMed2004

Sensitivity of an AIDS case-finding algorithm: who are we missing?

OBJECTIVE: The objective of this study was to determine the sensitivity of an AIDS case-finding algorithm. METHOD: This study applied the AIDS case-finding algorithm to paid Medicaid claims linked to New Jersey AIDS surveillance data and assesses its sensitivity across subgroups of patients. FINDINGS: Of the 7183 cases with confirmed AIDS, based on the state's registry information, 95% (n = 6818) were correctly detected using all Medicaid claims, including pharmacy. For patients in a community-based waiver program, covered by Medicare, diagnosed with a severe mental illness, or continuously enrolled in Medicaid, with regular contact with the medical system, the algorithm identified almost all patients. To further evaluate algorithm performance, it was used with 2 groups of interest to researchers. For AIDS patients in the last 6 months of life, 88% were correctly detected without use of pharmacy claims and 95% when pharmacy claims were included. For pregnant women, data from the 6 months before the latest delivery date identify 27% of pregnant women without pharmacy claims and 41% when pharmacy claims were included. Using claims made after the latest delivery date, 81% of pregnant women were detected without pharmacy claims and 93% when pharmacy claims were included CONCLUSION: Results demonstrate that a multilevel screen can be used with Medicaid claims to effectively to detect most patients with AIDS. Detection is lower for some subgroups, and the absence of pharmacy claims can compromise detection.

Acquired Immunodeficiency Syndrome↗
PubMed2000

Disability management, employee health and fringe benefits, and long-term-disability claims for mental disorders: an empirical exploration.

Mental disorders account for a large share of claims and benefit costs in both private and public long-term-disability (LTD) insurance programs. This is the first empirical study to explore factors that may explain variations in private-sector LTD claims incidence and cost across groups of employees. Employee fringe-benefit arrangements, including patterns of coverage for mental health treatment, are found to be important predictors of incidence rates. Award rates for public disability insurance coverage (SSDI) are also strongly related to claims incidence, suggesting that private LTD is an important pathway to SSDI benefits. Some employee disability-management strategies, such as front-line manager involvement and provision of alternative jobs for employees returning from disability leave, are predictive of lower claims rates and/or costs.

Adult↗
PubMed2002

Using administrative data to study persons with disabilities.

Administrative data result from administering health plans--tracking service utilization, paying claims, monitoring costs and quality--and have been used extensively for health services research. This article examines the strengths and limitations of administrative data for health services research studies of people with disabilities. Administrative data offer important advantages: encompassing large populations over time, ready availability, low cost, and computer readability. Questions arise about how to identify people with disabilities, capture disability-related services, and determine meaningful health care outcomes. Potentially useful administrative data elements include eligibility for Medicare or Medicaid through Social Security disability determinations, diagnosis and procedure codes, pharmacy claims, and durable medical equipment claims. Linking administrative data to survey or other data sources enhances the utility of administrative data for disability studies.

Data Collection↗
PubMed2004

A delay they can ill afford: delays in obtaining Attendance Allowance for older, terminally ill cancer patients, and the role of health and social care professionals in reducing them.

Despite a growing interest in holistic care for the terminally ill, financial needs are often not addressed. This is reflected in the fact that some people with a terminal illness are not accessing disability benefits, despite eligibility. The present paper is based on a study investigating delays experienced by cancer patients in obtaining Attendance Allowance (AA) by special rules, and missed opportunities for professionals to assist with claims. The study took place in a hospice where patients were referred to social work professionals for assistance in claiming AA. In each case, the patient had been eligible for some time before the referral. Over a 5-month period, all 22 patients who were referred completed a questionnaire. Data were collected to show their personal characteristics, how they came to be referred for assistance and their level of knowledge of AA. The length of time that people had already been eligible and the time taken to claim were recorded to show the amount of lost benefit. The health and social care professionals whom these patients had seen since becoming eligible were also recorded. A wide range of people experienced delays in accessing AA. Their total lost income ranged from pound 110.60 to pound 1106.00. The median was pound 387.10 and four people died before being awarded AA. Only four patients were fully aware of their eligibility. Every person had seen between one and four professionals since becoming eligible for the benefit, without the meeting resulting in a claim. Increased income aids the management of illness, and information and assistance to claim disability benefits need to be made available in a consistent manner at the earliest opportunity. Health and social care professionals are in a position to provide this. However, changes to the claims process, proposed by the present author, could ensure that AA is received automatically, without delay and without extensive paperwork.

Aged↗
PubMed1999

Evaluating Tackling Rugby Injury: the pilot phase for monitoring injury.

OBJECTIVE: To assess the suitability of two previously unused data sources for monitoring rugby injury throughout New Zealand. METHOD: Interviews were conducted with respondents sampled from players registered with the Rugby Football Unions (RFUs) and players claiming for rugby injuries from the Accident Rehabilitation and Compensation Insurance Corporation (ACC) in Auckland and Dunedin. RESULTS: Of the 500 RFU players sampled, 63% were interviewed and of these 39 (12%) had been injured playing rugby union. Of the 456 ACC claimants sampled, 66% were interviewed and 265 (88%) had been injured playing rugby union. CONCLUSION: Identifying injured players through ACC claims was more efficient, both procedurally and because a smaller sample size was required to detect changes in incidence. IMPLICATIONS: With no routine surveillance of sports injury being undertaken, recording sporting codes in national injury surveillance systems would assist the monitoring of sports injury.

Adolescent↗
PubMed1999

Classification system for complete edentulism. The American College of Prosthodontics.

The American College of Prosthodontists has developed a classification system for complete edentulism based on diagnostic findings. These guidelines may help practitioners determine appropriate treatments for their patients. Four categories are defined, ranging from Class I to Class IV, with Class I representing an uncomplicated clinical situation and a Class IV patient representing the most complex and higher-risk situation. Each class is differentiated by specific diagnostic criteria. This system is designed for use by dental professionals who are involved in the diagnosis of patients requiring treatment for complete edentulism. Potential benefits of the system include: 1) better patient care, 2) improved professional communication, 3) more appropriate insurance reimbursement, 4) a better screening tool to assist dental school admission clinics, and 5) standardized criteria for outcomes assessment.

Alveolar Bone Loss↗
PubMed1984

Epidemiologic study of dental emergencies among utilizers in an insured population in Washington, USA.

This is a study of the epidemiology of dental emergencies based on information abstracted from the microfilmed dental claim forms of a large American insurance program in 1981-82. Overall, about 4% of all dental visits were classifiable as emergencies. There were significant seasonal and age variations in dental emergencies. There was no variation with respect to geographic regions in the State of Washington (USA) or sex. Paradoxically, residents in regions having fluoridated water supplies were at equal risk of developing dental emergencies due to dental caries, relative to those residing in non-fluoridated regions. There was also no difference in risk associated with insurance deductibles, although generally deductibles are thought to deter first-contact visits.

Adolescent↗
PubMed1999

Travel insurance and health.

Travel insurance normally underwrites travel, medical, and dental expenses incurred by travelers abroad and arranges aeromedical evacuation of travelers under conditions specified by the travel insurance policy. Because of the costs of medical and dental treatment abroad and the high cost associated with aeromedical evacuation, all travelers should be advised of the need for comprehensive travel insurance and be advised to read their policies carefully to see what is covered and to check for any exclusions. In particular, those travelers who have known preexisting conditions, who are working overseas, or who are going to undertake any form of hazardous recreational pursuit may need to obtain a special travel insurance policy, which may attract a higher premium. Conservatively, it is estimated that between 30-50% of travelers become ill or injured whilst traveling. Relative estimated monthly incidence rates of various health problems have been compiled elsewhere. The risk of severe injury is thought to be greater for people when traveling abroad. These risks should be covered by travel insurance to protect the traveler, however it is not known what proportion of travel agents or airlines give advice routinely on travel insurance. Travel insurance is the most important safety net for travelers in the event of misadventure, and should be reinforced by travel health advisers. Although only 4% of general practitioners (GPs) in a late 1980's study in the United Kingdom would advise a traveler going to Turkey about travel insurance,4 more recent studies have shown about 60% of GPs in New Zealand and 39% of travel clinics worldwide usually advised travelers concerning travel insurance. In addition, 54% of GPs in New Zealand usually also advised travelers about finding medical assistance abroad, but only 19% of GPs recommended travel insurance companies as a source of medical assistance while traveling.

Humans↗
PubMed2000

Dental services, costs, and factors associated with hospitalization for Medicaid-eligible children, Louisiana 1996-97.

OBJECTIVE: This study compared types and costs of dental services rendered to children who had received care in a hospital operating room (H) with children who had not (NH). METHODS: The study population consisted of all children aged 1-5 years who received a dental service reimbursed by the Louisiana Medicaid EPSDT program from October 1996 through September 1997. Claim files were provided by the Louisiana Bureau of Health Services Financing. A treatment intensity index [TII = 3 x (# extractions) + 2 x (# pulpotomies + # crowns) + # simple restorations] was calculated for H children (n = 2, 142) and NH children (n = 38,423). Using logistic regression, a dichotomous hospitalization variable (H vs NH) was regressed against treatment intensity and selected personal and parish (county) characteristics for each of the five age groups. Total and average reimbursement per child were calculated for both groups of children, by age. RESULTS: The mean treatment intensity scores for H and NH children were 24.02 (SD = 11.82) and 2.16 (SD = 4.78), respectively. For all age groups, children with treatment intensity scores greater than 8 were at least 132 times more likely to be hospitalized than were children with scores less than or equal to 8. The mean cost for care provided to H children was $1,508 compared with $104 for NH. Total costs for dental care rendered to H children (5% of the study population) were $3,229,851 (45% of total dental costs for the study population). CONCLUSION: Reducing severe caries through early interventions could provide substantial cost savings.

Age Factors↗
PubMedDate not supplied

A rural hospital's use of software to determine accurate Medicare reimbursement levels.

This article details how a software program has helped a hospital collect more Medicare payments for which it was eligible than it previously had collected. The software simplifies the process of selecting complications by reminding the user when no complications have yet been entered, by determining whether each item entered qualifies as a complication, and by suggesting other possibilities. In many instances, these complications are possibilities that a person performing manual coding might not consider.

Concurrent Review↗
PubMed2002

Mental health insurance claims among spouses of frequent business travellers.

OBJECTIVES: Following up on two earlier publications showing increased psychological stress and psychosocial effects of travel on the business travellers this study investigated the health of spouses of business travellers. METHODS: Medical claims of spouses of Washington DC World Bank staff participating in the medical insurance programme in 1997-8 were reviewed. Only the first of each diagnosis with the ninth revision of the international classification of diseases (ICD-9) recorded for each person was included in this analysis. The claims were grouped into 28 diagnostic categories and subcategories. RESULTS: There were almost twice as many women as men among the 4630 identified spouses. Overall, male and female spouses of travellers filed claims for medical treatment at about a 16% higher rate than spouses of non-travellers. As hypothesised, a higher rate for psychological treatment was found in the spouses of international business travellers compared with non-travellers (men standardised rate ratios (RR)=1.55; women RR=1.37). For stress related psychological disorders the rates tripled for both female and male spouses of frequent travellers (>or= four missions/year) compared with those of non-travelling employees. An increased rate of claims among spouses of travellers versus non-travellers was also found for treatment for certain other diagnostic groups. Of these, diseases of the skin (men RR=2.93; women RR=1.41) and intestinal diseases (men RR=1.31; women RR=1.47) may have some association with the spouses' travel, whereas others, such as malignant neoplasms (men RR=1.97; women RR=0.79) are less likely to have such a relation. CONCLUSION: The previously identified pattern of increased psychological disorders among business travellers is mirrored among their spouses. This finding underscores the permeable boundary between family relations and working life which earlier studies suggested, and it emphasises the need for concern within institutions and strategies for prevention.

Adult↗