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PubMed1999

Possibilities and limitations in the functional use of medical practice profiles.

The first use of medical practice profiles in the Belgian healthcare organization goes back to 1980 with the creation of practice pattern evaluation at the National Institute of Health and Invalidity Insurance (RIZIV). Since then, detailed information on the provision and on the utilization of healthcare has become increasingly important in the planning, budgeting and financing of the nation healthcare. The RIZIV uses practice profiling predominantly as a means to control aberrant prescription (e.g. clinical chemistry, medical imaging, pharmaceuticals) and provision of care (diagnostic tests). In 1991, the Federal Ministry of Health started using data on diagnosis and medical performance for hospital admissions in order to adapt the per diem price and the yearly quotum of admission days attributed to each hospital. At the level of the health insurer (sickness funds) there is growing interest to share the information derived from the extremely detailed patient claims for reimbursement of intramural and ambulatory care. These billing data allow the evaluation of medical care provision per physician, per hospital or provision center and per patient for a given period of time. The lack of specific diagnosis indication restricts mainly the use of these data as medical performance parameter to surgical procedures. The purpose of this profile information for the health insurer is to point to the physician the important medical practice variability in identical clinical situations in order to stimulate the design and implementation of practice guidelines and reduce aberrant differences in practice patterns. The use of medical practice profiles, in close collaboration of insurers and providers is considered extremely valuable as a means to improve the quality of healthcare provision.

Ambulatory Care↗
PubMed1999

Falling behind in the payment game. Providers are feeling squeezed by HMOs that don't pay on time and keep changing the rules.

When hospitals provide services, they naturally expect to be paid. But providers are waiting longer and longer for payment from HMOs, sometimes 90 to 120 days, putting the squeeze on cash flow. The problem has led states to enact prompt-payment laws. Health plans defend their record, saying hospitals' billing mistakes and antiquated computer systems are often to blame for the tardy payments.

Accounts Payable and Receivable↗
PubMed1999

The UR controversy.

Explore the source record for details and available documents.

Concurrent Review↗
PubMed1999

Case managers reorganize to challenge claims denials.

A combination of diminished reimbursement, decreased funding for residency programs, an epidemic of claims denials, and the skilled nursing crisis has imperiled teaching hospitals across the country. Increasingly, these hospitals are looking to case management departments as potential saviors. In the short term, that could mean more staff and a beefier budget, but if your department can't produce, cuts later on could be drastic. The University of Pennsylvania Health System in Philadelphia lost $90 million in FY1998 and responded by cutting 1,100 positions--9% of its work force. The case management department lost eight positions and is trying to take up the slack with a massive reorganization of its care delivery system and a rigorous education program designed to reduce claims denials. At Georgetown University Medical Center in Washington, DC, however, case management staff and resources have been increased for now. The department is using its new-found prosperity to thoroughly screen all incoming patients for appropriateness of admission, upgrade its discharge planning capabilities, and hire a full-time employee to appeal denied claims.

Academic Medical Centers↗
PubMed1999

Using hospital-based case management to reduce payer denials.

Peninsula Regional Medical Center in Salisbury, Maryland, sought to implement a case management program to reduce a rising number of denied claims for avoidable, nonacute-care inpatient days. Initial efforts focused on consolidating functions rather than monitoring and managing care, and denied claims continued to increase. A revised case management program based on assertive resource management rapidly and substantially reduced claim denials.

Case Management↗
PubMed1999

Insurance policies may cover costs of False Claims Act litigation.

Expenses associated with the defense of a False Claims Act investigation or lawsuit may be covered by insurance. Such coverage may be available through a general liability policy, or in the case of not-for-profit organizations, through a provision added to the organization's directors and officers policy. In either instance, the extent of coverage is determined by the language used in the policy and state law governing interpretation of the insurance policy.

Costs and Cost Analysis↗
PubMed2000

Doctors' complaints help forge insurance regulation. Payment due.

Arkansas doctors are banning to help draft a regulation that would require health maintenance organizations and insurance carriers to process health care claims within 45 calendar days after receipt of a claim. The proposed regulation would be administered by the Arkansas Department of Insurance. If additional information from a claimant is needed to process a claim, a carrier must notify a provider within 10 days of receipt of the claim. Once that information is received by the carrier, it has an additional 45 days to pay.

Arkansas↗
PubMed2000

[Malpractice in connection with radius fractures must be reduced. Clear guidelines for treatment and follow-up are required].

PSR handles the vast majority of malpractice injuries in Sweden. PSR is a claims handling company which settles claims for malpractice on behalf of the insurance company owned by the Swedish county councils: the County Councils Mutual Insurance Company. A central issue in the law regulating patient injuries in Swedish health care is to define injuries that could have been avoided if a certain therapeutic/diagnostic procedure or a more appropriate method had been utilized. PSR arranged a multiprofessional conference regarding guidelines to decrease the number of malpractice injuries in the treatment of distal radius fractures. Among the most important issues defined were: To improve and standardize diagnostic imaging Patient information Early decision making in surgery and physical/occupational therapy A more well-defined indication for surgery, in which type of trauma, biological age and functional demands are considered in addition to radiographs Less stereotyped thinking in follow-up Controlled randomized trials.

Clinical Competence↗