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PubMed1997

Sensitivity and positive predictive value of Medicare Part B physician claims for rheumatologic diagnoses and procedures.

OBJECTIVE: To examine the sensitivity and positive predictive value of Medicare physician claims for select rheumatic conditions managed in rheumatology specialty practices. METHODS: Eight rheumatologists in 3 states abstracted 378 patient office records to obtain information on diagnosis and office procedures. The Medicare Part B physician claims for these patient visits were obtained from the Health Care Financing Administration. The sensitivity of the claims data for a specific diagnosis was calculated as the proportion of all patients whose office records for a particular visit documented that diagnosis and who also had physician claims for that visit which identified that diagnosis. The positive predictive value was evaluated in a separate sample of 331 patient visits identified in Medicare physician claims. The positive predictive value of the claims data for a specific diagnosis was calculated as the proportion of patients with that diagnosis coded in the claims for a particular visit who also had the diagnosis documented in the medical record for that visit. RESULTS: Ninety percent of abstracted office medical records were matched successfully with Medicare physician claims. The sensitivity of the Medicare physician claims was 0.90 (95% confidence interval [CI] 0.85-0.95) for rheumatoid arthritis (RA), 0.85 (95% CI 0.73-0.97) for systemic lupus erythematosus (SLE), and 0.85 (95% CI 0.78-1.0) for aspiration or injection procedures. The sensitivity for osteoarthritis (OA) of the hip or knee was < or = 0.50 if 5-digit codes specifying anatomic site were required. The sensitivity for fibromyalgia (FM) was 0.48 (95% CI 0.28-0.68). The positive predictive values were at least 0.90 for RA, SLE, and aspiration or injection procedures. Positive predictive values for FM and the 5-digit site-specific codes for OA of the knee were 0.83 (95% CI 0.66-1.0) and 0.88 (95% CI 0.75-1.0), respectively, while the positive predictive value of the 5-digit site-specific codes for OA of the hip was zero (95% CI 0-0.26). The positive predictive value of OA at any site was 0.83 (95% CI 0.76-0.90). CONCLUSION: In specialty practice, Medicare physician claims had high sensitivity and positive predictive value for RA, SLE, OA without specification of anatomic site, and injection or aspiration procedures. The claims had lower sensitivity and predictive value for FM and for OA of the hip. The accuracy of Medicare physician claims for other conditions and in the primary care setting requires further investigation.

Aged↗
PubMed2005

Medicaid program; state allotments for payment of Medicare Part B premiums for qualifying individuals: federal fiscal year 2005. Interim final rule with comment period.

This interim final rule with comment period sets forth the methodology used to compute State allotments that are available to pay Medicare Part B premiums for qualifying individuals, allows changes to the State allotments and describes the methodology used to determine the changes to each State's allotment.

Health Care Rationing↗
PubMed2004

Medicare program; manufacturer submission of manufacturer's average sales price (ASP) data for Medicare Part B drugs and biologicals. Final rule.

On April 6, 2004, we published an interim final rule in the Federal Register implementing the provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) related to the calculation and submission of manufacturer's average sales price (ASP) data on certain Medicare Part B drugs and biologicals by manufacturers. This final rule responds to the public comments received on the interim final rule concerning the methodology for estimating price concessions associated with manufacturers' ASP reporting requirements. Other issues and comments relating to the interim final rule will be addressed at a future time.

Drug Costs↗
PubMed2006

Medicaid program; state allotments for payment of Medicare Part B premiums for qualifying individuals: federal fiscal year 2006. Interim final rule with comment period.

This interim final rule with comment period sets forth the methodology and process used to compute and issue each State's allotment for fiscal year (FY) 2006 and FY 2007 that is available to pay Medicare Part B premiums for qualifying individuals. It also provides the preliminary FY 2006 allotments determined under this methodology.

Cost Sharing↗
PubMed1998

Medicare program; application of inherent reasonableness to all Medicare Part B services (other than physician services)--HCFA. Interim final rule with comment period.

This interim final rule implements section 4316 of the Balanced Budget Act of 1997. It revises the process for establishing a realistic and equitable payment amount for all Medicare Part B services (other than physician services) when the existing payment amounts are inherently unreasonable because they are either grossly excessive or deficient. This rule describes the factors HCFA (or its carrier) will consider and the procedures it will follow in establishing realistic and equitable payment amounts.

Aged↗
PubMed2006

Medicaid program; state allotments for payment of Medicare Part B premiums for qualifying individuals: federal fiscal year 2006 and fiscal year 2007. Final rule.

This final rule sets forth the methodology and process used to compute and issue each State's allotments for fiscal years (FY) 2006 and FY 2007 that are available to pay Medicare Part B premiums for qualifying individuals. It also provides the final FY 2006 allotments and the preliminary FY 2007 allotments determined under this methodology. We are also confirming the April 28, 2006 interim final rule as final.

Eligibility Determination↗
PubMedDate not supplied

A new Medicare Part B wound care policy.

Skin and wound care specialists should design an assessment tool that includes all the documentation required to prove medical necessity for the initial and continued use of NPWT, when appropriate for patients who are managing their wounds at home. In addition, specialists should supply the physician with the order form that is provided by the NPWT pump supplier. Finally, personnel should be trained to appropriately assess and document the need for NPWT. Once a Medicare Part B-covered patient at home qualifies for a NPWT pump and supplies, the supplier will deliver the equipment and supplies and will bill Medicare Part B directly. Payment will be 80% of the DMERC Fee Schedule. The patient will be charged 20% of the Medicare allowable fee.

Aged↗
PubMed1987

Medicare Part B: rising assignment rates, rising costs.

In this paper I examine the access, quality, and cost trade-offs of assignment under Part B of the Medicare program for both participating and nonparticipating practices, and discuss the impact of assignment on both physician and patient choices. I also discuss the assignment options, or variants of assignment, that have been pursued and that might be considered for future implementation to curb increases in physician costs. Although one frequently suggested alternative--mandatory assignment--would reduce much of the uncertainty surrounding physician costs and reduce some of the out-of-pocket costs of the elderly, it could promote a two-tier system of care by reducing quality for Medicare beneficiaries, and may produce increases in government expenditures.

Costs and Cost Analysis↗
PubMed1995

The effectiveness of Medicare Part B medical review: issues and alternatives.

The part B medical review methods currently used by Medicare carriers to control resource use suffer from a series of problems including failure to reward deterrence of unnecessary claims, failure to detect substitution of nonreviewed claims, reliance on average rather than marginal measures of performance, excessive focusing of reviews, and the inability to measure effectiveness separately from the intervention. This article describes these problems and proposes a series of alternative strategies for review that may improve these problems.

Cost-Benefit Analysis↗