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PubMed1995

Must insurance payments made in error be returned?

Healthcare organizations sometimes receive payments made in error from insurance companies. Such payments may occur when insurance companies do not determine that a person receiving care was not covered until after the care has been provided and the bill has been paid. A review of pertinent cases in this area suggests that a legal precedent exists for viewing a healthcare organization as an innocent third-party creditor, thus absolving it of the responsibility to return the mistaken payment.

Accounts Payable and Receivable↗
PubMed1994

Use of diagnosis-related groups by non-Medicare payers.

Medicare's prospective payment system (PPS) for hospital cases is based on diagnosis-related groups (DRGs). A wide variety of other third-party payers for hospital care have adapted elements of this system for their own use. The extent of DRG use varies considerably both by type of payer and by geographical area. Users include: 21 State Medicaid programs, 3 workers' compensation systems, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), more than one-half of the Blue Cross and Blue Shield Association (BCBSA) member plans, several self-insured employers, and a few employer coalitions. We describe how each of these payers use DRGs. No single approach is dominant. Some payers negotiate specific prices for so many combinations of DRG and hospital that the paradigm that payment equals rate times weight does not apply. What has emerged appears to be a very flexible payment system in which the only constant is the use of DRGs as a measure of output.

Data Collection↗
PubMedDate not supplied

The Medicare Transaction System Initiative.

Here is a progress report on the Medicare Transaction System Initiative originally reported in these pages about two years ago. In addition, the author describes some of the interim steps HCFA is taking in preparation for the move to MTS.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1995

Medicaid program; third party liability (TPL) cost-effectiveness waivers--HCFA. Final rule.

This final rule revises regulations concerning Medicaid agencies' actions where third party liability (TPL) may exist for expenditures for medical assistance covered under the State plan. It allows the Medicaid agencies to request waivers from certain procedures in our regulations that are not expressly required by the Social Security Act. We will consider waiving nonstatutorily required procedures relating to identifying possible TPL where the agency finds that following a given required procedure is not cost-effective and is duplicative of another State activity. A nonstatutorily required activity is eligible for a waiver if the cost of the required activity exceeds the TPL recoupment and the required activity accomplishes, at the same or at a higher cost, the same objective as another activity that is being performed by the States. This change gives States greater flexibility in managing their Medicaid programs.

Cost-Benefit Analysis↗
PubMed1992

Stratification, competition and risk distribution: health insurance in Germany and the United States.

Issues of unequal risk distribution among sickness funds are given increasing attention in the current discussions on the reform of the statutory health insurance system in Germany. This paper examines the structural determinants of risk distribution and points toward the links between social stratification, competition, health risk and insurance status. A model showing the links between basic structural determinants is presented. Using health survey data from Germany and the U.S., statistical analyses are conducted. The results support the model and indicate its applicability for both health care systems. The paper concludes by indicating the relevance of such findings for health policy and future research.

Economic Competition↗
PubMed1993

An economic analysis of pancreas transplantation: costs, insurance coverage, and reimbursement.

Since 1988 the demand for the pancreas transplantation has continued to increase. This has been accompanied by a growth in the number of centers offering the procedure, and an increase in the number of transplants performed. The National Cooperative Transplantation Study was undertaken to document the costs of all transplants, including pancreas transplantation. Data on transplantation procedure charges, from date of transplant to discharge, were obtained from 66.7% of all pancreas transplantation programs active in 1988. These programs accounted for 72% of all transplants performed that year. Valid sample survey data (no more than 25 transplants per center) were obtained for 133 randomly selected patients. This constituted 54% of all procedures done in the United States in 1988. Detailed data were also collected on sources of payment and amount reimbursed. Due to outlier data, we report statistical medians, rather than means, as our measure of central tendency. The median charge for a pancreas transplant with or without a kidney was $66917, with a hospital length of stay of 21 days, compared with a kidney transplant alone at $39625 and a hospital length of stay of 14 days. Total pancreas transplant charges fell between $45260 and $105375 for 50% of the cases studied. Half of the patients had a hospital length of stay between 16 and 33. Due to the small number of cases available for analysis, it was not meaningful to cross-classify the data according to various prognostic variables.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMedDate not supplied

Storm warning. Insurance regulation.

Pressure is mounting on state insurance commissioners to treat provider-run health networks like insurers. Like a distant tropical depression, this potential threat to collaborative networks hasn't shown up on the radar screens of most hospitals. But it will. Put on your galoshes.

American Hospital Association↗
PubMedDate not supplied

I've got a secret.

Explore the source record for details and available documents.

Computer Security↗