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Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

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At least 613 records · Page 34Linked to original sources
PubMed1994

Impact of AIDS/HIV on medical directors.

The decade of AIDS/HIV has changed the way insurance medicine is practiced by medical directors. One director details some of these changes.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Integrating payer and provider risk through capitation.

Capitation payment mechanisms promote conservative use of medical resources by transferring risk to the decision maker, the physician. However, there is another view of capitation: defining common risk between provider-driven organizations (i.e., physician/hospital organizations (PHOs) or integrated delivery systems (IDS), and risk-managing entities such as HMOs or insurance companies. This article discusses a strategy to align provider and risk manager incentives to share the risks and rewards for a total book of business or population.

Actuarial Analysis↗
PubMed1997

Medicare program; Medicare appeals of individual claims--HCFA. Final rule with comment period.

Under section 1869 of the Social Security Act, Medicare beneficiaries and, under certain circumstances, providers or suppliers of health care services may appeal adverse determinations regarding claims for benefits under Medicare Part A or Part B. This rule expands our regulations to recognize the right of Part B appellants to a hearing before an administrative law judge (ALJ) for claims if at least $500 remains in dispute and the right to judicial review of an adverse ALJ decision if at least $1,000 remains in controversy. Also, this rule codifies in regulations: Limitations on the review by ALJs and the courts of certain national coverage determinations, and the statutory authority for an expedited appeals process under Part A and Part B.

Centers for Medicare and Medicaid Services, U.S.↗
PubMedDate not supplied

Medicaid. Can IT help administer HEDIS?

Stopping the revolving door of care for Medicaid recipients is the first step in providing quality-based services regardless of an individual's income level or insurance carrier. But before these changes can be measured, managed care officials must confront some of the problems inherent to Medicaid, such as: unregulated and unrecorded migration of plan enrollees; data collection from disparate sources; and the availability of few information system resources.

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