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PubMed1995

The Medicare Transaction System Initiative.

The Health Care Financing Administration is developing a system that will effectively use information technology to reduce paperwork and streamline the processing of claims. This system, targeted to be up and running by late 1997, will usher in a new model of convenience for providers, payers, and clients.

Ambulatory Care Information Systems↗
PubMed1995

Pulling the coverage trigger: the temporal condition of liability insurance.

Timing issues will continue to be at the forefront of insurance coverage disputes for a long time, and may impact not only the question of which insurer is responsible for a particular loss, but also whether any coverage exists at all. For example, if a policyholder has self-insured for any period, the timing issue may well determine whether purchased liability insurance will afford any protection for the loss. Though courts have provided useful guidelines, in order to determine coverage the facts of each case must be carefully examined, particularly the policy language and the nature of the injury on which the claim is founded. When there are difficult timing questions, one viable approach may be for the policyholder to select a "target" insurer to sue for coverage, based in part on the timing analysis, and leave to the targeted insurer the task of seeking contribution from all other carriers potentially responsible for covering the loss.

Eligibility Determination↗
PubMed1995

An alternative method for the identification of potential habitual narcotic users from a managed care claims database.

The purpose of this study was to identify an alternative method of initial narcotic abuse screening to distinguish members who have a greater likelihood of being correctly classified as potential narcotic abusers. Members 10 years of age and older, who had one or more pharmacy claims for narcotics within a quarter were included in the analysis. Members were classified according to the number of narcotic prescriptions, unique pharmacies, and unique physicians in a quarter. Those with excluded medical conditions and abuse-related diagnoses were identified. A narcotic abuse decision tree was developed to identify population(s) with the highest likelihood for a potential abuse history. Using a combination of variables, especially age, strengthened the likelihood of identifying potential narcotic abusers.

Data Interpretation, Statistical↗
PubMed1996

Preferred provider organizations and physician fees.

Preferred provider organizations (PPOs) represent a form of managed care in which providers agree to accept discounted fees in exchange for the expectation that their patient volume will increase or at least be maintained. Managed care plans that rely on discounted fee-for-service (FFS) payments have increased from about 10 plans in 1981 to over 700 plans in 1994. In this study, we document levels of discounts achieved by two large national insurers and discuss how the size of the discount varies by type of service and how the discounted rates relate to Medicare fees. Our results show that, despite achieving large discounts (approximately 10 20 percent) relative to their indemnity plans, the two nationwide PPOs studied here pay at rates substantially above Medicare levels.

Fee-for-Service Plans↗