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PubMed2001

Coding and reimbursement issues for the radiologist.

Radiologists are dependent on the proper execution of a complex administrative chain of disease and diagnosis coding and procedural coding to be properly reimbursed for the examinations they perform. The radiologist bears the ultimate responsibility for the appropriateness of these codes. However, many practicing radiologists are unaware of the critical link between the two coding systems and the systems that have developed to provide a common method of describing diseases, diagnoses, and procedures. This article is an introduction to these systems, and it emphasizes the importance of the involvement of the radiologist in coding. The inherent complexity of the reimbursement system in use is emphasized, as well as the essential role of the radiologist in complying with these often complicated and ever-changing directives.

Electronic Data Processing↗
PubMed1980

Accuracy of diagnostic information submitted to an insurance company.

Findings from two studies of the utilization of the mental health benefit under the Washington, D.C., area Blue Cross and Blue Shield Federal Employees Program suggest that diagnostic information submitted to insurance companies on claims forms is often inaccurate and therefore of little use for claims or peer review. The authors conclude that inaccurate information is submitted primarily because of legitimate concerns about patient confidentially. The urge that special claims and peer review procedures be developed to assure confidentiality of sensitive clinical information. A pilot project developed by the Washington Psychiatric Society and Blue Cross and Blue Shield is offered as an example of the kinds of systems that need to be devised.

Blue Cross Blue Shield Insurance Plans↗
PubMedDate not supplied

Exploring racial disparity in posttraumatic stress disorder diagnosis: implications for care of African American women.

OBJECTIVE: To explore factors contributing to disparities in posttraumatic stress disorder (PTSD) diagnosis between African Americans and White Americans, while controlling for gender and class by using a data set limited to poor women. DESIGN: A cross-sectional epidemiological secondary analysis. SETTING: Michigan Medicaid fee-for-service claims data from 1994 through 1997. SAMPLE: A total of 20,298 African American and White American adolescents and adult women, including 2,996 with PTSD diagnosis. MAIN OUTCOME MEASURES: Victimization, PTSD diagnosis, psychiatric and somatic comorbidities, and PTSD treatment. RESULTS: African American women were under-represented in the group diagnosed with PTSD (12% versus 31% in the comparison group), despite having equal rates of hospitalization for rape and battering. They were less likely to be diagnosed with comorbidities associated with complex PTSD, such as dissociative disorder (OR = 0.259, p < .001) or borderline personality disorder (OR = 0.178, p < .001), but were equally likely to be diagnosed with conduct disorder, schizophrenia, or substance abuse. African American women were 40% less likely to have continuous insurance coverage. CONCLUSIONS: Patient, provider, and system factors appear to interact to create disparities in PTSD diagnosis and treatment. Attention to case finding and provider or system bias may help reduce disparities.

Adolescent↗
PubMed2006

Characteristics and antecedents of progressive multifocal leukoencephalopathy in an insured population.

Based on health insurance claims from a large U.S. health insurer, the authors identified 44 progressive multifocal leukoencephalopathy (PML) cases from 2002 through 2004 and described their characteristics, including antecedent diagnoses and treatments as well as survival. Immunosuppressive conditions such as HIV/AIDS, rather than potentially immunosuppressive treatments, were the main antecedents of PML. A lower mortality was observed among PML patients whose antecedent diagnosis was HIV/AIDS, the majority of whom received highly active antiretroviral therapy.

Adolescent↗
PubMed1992

The effects of tort reform on medical malpractice insurance markets: an empirical analysis.

I use statewide loss ratio data to assess empirically the manner in which tort reforms have affected relative prices and profitability, and underwriting risk in the medical malpractice insurance industry. The empirical evidence suggests that the imposition of statutory ceilings on recoveries both decreased risk and improved relative profitability. Reforms that codified the required standard of care appeared to have a beneficial effect on relative profitability in certain cases.

Humans↗
PubMed1996

Medical malpractice in Michigan: an economic analysis.

We analyzed the factors determining the amount of the recovery on claims based on medical malpractice. Our data set, which previously was not explored, consists of 20,428 claims arising within Michigan that were closed between 1978 and 1990. During this period, major changes were made in the law governing malpractice litigation. We determine the effect of these changes and of various other factors affecting medical malpractice claims. We analyze the effect of a statute that was designed to curtail "forum shopping" by attorneys for plaintiffs. This statute was initially successful in curbing such activity, but its effect seems to be diminishing. In addition, we compare mediation awards with settlement payments, and settlement payments with the expected value of claims in litigation. Evidence suggests that a mediation award is the mediation panel's estimate of a settlement payment appropriate for the case, and that cases are settled for substantially less than their expected value at trial.

Health Care Reform↗
PubMed1999

No-fault vaccine insurance: lessons from the National Vaccine Injury Compensation Program.

During the first eight years of the National Vaccine Injury Compensation Program (NVICP), 786 contested claims were resolved through published judicial opinions. The likelihood of compensation dependent in part on the closeness of the match between the described injury and a specified list of acknowledged untoward vaccine side effects. In addition, the chances of applicant success were influenced by the applicant's choice of attorney and expert witnesses, by the assignment of the Special Master to decide the case, and increasingly over time, by the applicant's ability to comply with procedural requirements. The majority of contested claims arose from pertussis immunizations. For pertussis claims, the goal of insulating manufacturers from product liability suits has been achieved by granting compensation to applicants whose injuries are not scientifically recognized effects of the vaccine. In spite of (or because of) this jarring contradiction between the legal and medical understanding of causation, vaccine availability and childhood immunization rates improved during the early years of the plan. The apparent success of the program may encourage the substitution of no-fault compensation plans for tort-based consumer protection for other products, both medical and nonmedical.

Adolescent↗
PubMed2000

The jury is still in: Florida's Birth-Related Neurological Injury Compensation Plan after a decade.

Florida's Birth-Related Neurological Injury Compensation Plan (NICA) is the most significant experiment with compensation for medical injury yet undertaken in the United States. As NICA enters its second decade of operation, maintaining the scheme's jurisdictional integrity has emerged as a key challenge for policy makers in Florida. We explore the relationship that has emerged between NICA and the tort system as competing avenues for families to obtain compensation for severe birth-related neurological injury. By linking NICA claims data with data on malpractice claims filed in Florida, we found a lively persistence of "bad baby" litigation despite NICA's implementation. Many families pursued claims in both fora. An explanation for these results can be traced to key features of the plan's design--primarily, the way in which "exclusive" jurisdiction over injuries is determined and the restrictive nature of the compensation criteria used. Our findings may help efforts to consolidate NICA's role in injury compensation and inform future design of alternative compensation systems.

Birth Injuries↗
PubMed1980

Regional variations in the determinants of professional liability claims.

The problem of professional liability claims and impact on the medical care market has become increasingly important in recent years. Professional liability insurance premiums, and the practice of defensive medicine by physicians in response to potential professional liability claims, have been cited as partly responsible for the increasing costs of medical care. This study is an analysis of factors which influence the probability of a professional liability claim occurring for physicians in each of the four Census Regions. The data analyzed are from the Eleventh Periodic Survey of Physicians conducted by the American Medical Association in 1977, in which respondents indicated whether they had a professional liability claim filed against them. A logit analysis suggests that variations across Census Regions in population characteristics, availability of medical resources and supply of legal services are determinants of the occurrence of claims.

Catchment Area, Health↗
PubMed1982

Employer-based health insurance.

Employer-based health insurance (insurance that is purchased by employers for their employees and financed through employer or joint employer-employee contributions) is currently subsidized in part by the federal government through tax exclusions for employer contributions to employee health insurance plans. This subsidization costs the federal government close to 10 billion dollars a year in lost revenues. Many proposed national health insurance plans assign a key role to employer-based health insurance as a vehicle for financing health care. Federal subsidization of employer-based health insurance and plans that assign employers a key role in the administration of a national health insurance plan both assume that private industry acts to realize federal health policy goals-- particularly cost containment--in administering health insurance plans. Little is known, however, about how employers go about selecting the plans they offer their employees or about the incentives and disincentives regarding cost of care than are created by employer-based health insurance. Existing evidence suggests that rather than helping to contain health care costs, employer-based health insurance may be partly responsible for their present escalation. In addition, employer-based health insurance may not be the most equitable way to implement a national health insurance plan.

Blue Cross Blue Shield Insurance Plans↗
PubMed1994

Image quality of intraoral radiographs used by general practitioners in prosthodontic treatment planning.

A number of studies have shown a low standard of radiographic image quality in general dental practices. Image quality was evaluated on 1094 radiographs from 100 consecutive cases submitted to a dental insurance office for approval of planned prosthodontic treatment. It was found that only 404 radiographs were without any type of error and that 690 radiographs had a total of 959 errors. The most common errors were projection and film density errors. The number of submitted radiographs ranged from one to 40. Nearly every fourth tooth proposed for treatment was not properly documented. The results also showed that 43 of 100 cases did not meet the criteria for acceptance for assessment of the proposed prosthodontic treatment. This means that they were incompletely documented radiographically so that the treatment plan could not be evaluated. This study suggests that new or additional radiographic documentation ought to be requested frequently before approval of proposed treatment plans.

Denture, Partial, Fixed↗
PubMed1995

Revenue enhancement through total quality management/continuous quality improvement (TQM/CQI) in outpatient coding and billing.

To survive and thrive, rural hospitals are seeking enhanced revenues. This study focuses on outpatient laboratory and radiology coding and billing accuracy in a nonrandom sample of seven rural hospitals in a Western state. Information was gathered on (1) procedures incorrectly coded, (2) potential revenue increases from correct coding and billing, (3) barriers to implementing changes, and (4) perceived audit value. The identified major source of potential revenue enhancement was increased fees from private payers. Correct coding and billing to Medicare and Medicaid offered the potential of additional revenue. Participating administrators appreciated the validation of coding and billing practices and identification of potential enhanced revenues. Five of seven hospitals (71.4%) selectively implemented recommended changes. Complete compliance with recommended changes was limited by barriers of tradition, competition, and reimbursement, which must be overcome to realize successful implementation. Joint Commission on Accreditation of Healthcare Organization's (JCAHO) new Total Quality Management/Continuous Quality Improvement (TQM/CQI) emphasis provides an opportunity for revenue enhancement through coding/billing assessments and interdepartmental focus and coordination.

American Hospital Association↗
PubMed2001

Dually eligible individuals with AIDS: characteristics and health services use.

This paper explores the prevalence and health care utilization of dually eligible Medicare and Medicaid participants among New Jersey Medicaid recipients with AIDS using linked administrative data. Merged Medicaid claims and AIDS surveillance data were used to analyze participation in the Medicare program by Medicaid recipients in New Jersey diagnosed with AIDS who received services between January 1988 and March 1996. We found that nearly 30% of Medicaid participants had Medicare claims during the observation period, suggesting that Medicare is becoming an important payer of HIV care among individuals eligible for Medicaid. Traditionally disadvantaged groups such as women and racial minorities were less likely to be dually eligible for Medicare, reflecting differences in survival and in eligibility requirements for Social Security Disability Insurance (SSDI). Controlling for other characteristics, dually eligible individuals had shorter lengths of stay and had lower charges per inpatient stay than Medicaid only enrollees. Dual eligibles were also more likely to use antiretroviral (ARV) drugs and were more consistent users of ARV treatment measured by the proportion of time on ARV therapy. Our study suggests that persons with AIDS who may qualify for Medicare because of their disability are different than individuals who only received Medicaid reimbursed services in terms of their health care utilization. Further research is needed to determine the cause of such differences which may include socioeconomic differences between dual eligibles and Medicaid only eligibles, dissimilarities in health status between the two groups, and variation in aspects of insurance coverage particularly in the choice and reimbursement of office-based physicians.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Negotiating with third party payers: one community pharmacy's experience.

OBJECTIVES: To evaluate financial terms and legal wording in insurance contracts and negotiate their terms with companies to improve an independent pharmacy's financial position and to determine the time required to negotiate a contract and translate that time into a salary cost. SETTING: An independent pharmacy in a small town in Alabama with a population of approximately 6,000. PRACTICE DESCRIPTION: The prescription department accounts for two-thirds of the pharmacy's sales and dispenses approximately 70,000 prescriptions each year. Insurance companies paid for over 59% of these prescriptions in 2000. The pharmacy is open 7 days a week with one full-time pharmacist and a second pharmacist who works 2 days a month. PRACTICE INNOVATION: A contract negotiation form was developed that addressed factors that might affect a pharmacy's decision to accept or reject a contract; the form included an area for recording the time involved in negotiating each contract. INTERVENTIONS: Insurance companies selected by the pharmacy owner were faxed copies of an Insurer Demographics Collection Form. Upon collection of all data and finalization of proposed changes, a copy of the contract with the proposed changes marked, along with a letter explaining and justifying the changes, was sent to the insurance company. If no response was received from the company, the contact person was called and negotiations proceeded over the telephone. MAIN OUTCOME MEASURES: Primary end points were the percentage of companies that would negotiate and the average increase in reimbursement achieved. Secondary end points included the time involved in negotiations and the translation of that time into a salary cost. RESULTS: None of the nine participating companies accepted any of the changes proposed. The time to negotiate each contract ranged from 28 minutes to 74 minutes, taking an average of 48.4 minutes. Depending on the division of work between the pharmacist and the technician, the salary cost for the negotiations ranged from $14.68 to $18.73 per contract. CONCLUSION: This study provides a realistic description of attempts at contract negotiation between one pharmacy and nine third party payers. The difficulty of achieving successful results and the necessity of carefully considering the time and cost of contract negotiations underscore how important it is for independent pharmacists to concentrate their efforts on contracts and terms they have an opportunity to change.

Alabama↗