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Catastrophic coverage only.
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Straight talk: new approaches in healthcare. Are you in denial over your denials? Enhance your revenues with denial management.
Most health systems lose between 3% and 5% of net revenues as a result of payment denials from insurance companies. But it doesn't have to be that way. In the eighth installment of Straight Talk, we talk about the steps necessary to recover lost revenue through a denial-management program, which involves an investment in information technology and a commitment to business-process change. Denial management isn't just the responsibility of the employees in patient financial services--it's everyone's responsibility at the hospital. Modern Healthcare and PricewaterhouseCoopers present Straight Talk. The session on denial management was held at Modern Healthcare's Chicago headquarters on November 6, 2002. Charles S. Lauer, Publisher of Modern Healthcare, was the moderator.
Navigating payment pitfalls in managed care.
Healthcare providers need to identify and address payment problems relating to denied or underpaid claims. Before contract renegotiation, providers should identify the total dollar amount of claims that are denied or underpaid for each payer. Providers should choose managed care contract information systems that can grow with the hospital's managed care volume. Providers should identify all underpayment problems before negotiating a settlement with a payer.
Patient reports of coverage denial: association with ratings of health plan quality and trust in physician.
OBJECTIVE: To evaluate whether HMO patients' reports of denial of coverage were associated with their ratings of health plan quality and trust in their physician. STUDY DESIGN: Cross-sectional survey. PATIENTS AND METHODS: Within a mixed-model HMO, we surveyed 2000 adult patients who had seen a clinician at least once during the previous year. RESULTS: Of the 2000 patients, 921 (46%) responded. Denial of coverage within the previous 12 months was reported by 64 (7%) patients. Among the denials, 42% were for specialist referral, 32% were for tests or treatments, 18% were for a certain length of hospital stay, and 8% were for a hospital admission. Patients scoring in the lowest quartile on physical functioning were more than twice as likely as other patients to report denial of coverage (12.2% vs 5.1%, P = .001). In multivariable analyses, poor physical functioning remained the only significant independent variable associated with reporting denial of coverage (odds ratio = 3.0; 95% confidence interval, 2.4, 3.6). More than half (53%) of patients reporting denial of coverage said that they had considered leaving the health plan because of concerns about quality of care. These patients also were less likely to express high trust in their primary care physician (64% vs 78%, P < .001). CONCLUSIONS: Patients with poor physical functioning were more likely to report denial of coverage. Perceived denial of coverage was associated with lower ratings of health plan quality and with significantly less trust in patients' own primary care physicians.
Hire right, or pay the price.
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HMO disputes on coverage often don't involve necessity.
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Medicare program; improvement to the Medicare+Choice appeal and grievance procedures. Final rule with comment period.
This final rule with comment period responds to comments on the January 24, 2001, proposed rule regarding improvements to the Medicare+Choice (M+C) appeal and grievance procedures. It establishes new notice and appeal procedures for enrollees when an M+C organization decides to terminate coverage of provider services. The January 24, 2001 proposed rule was published as a required element of an agreement entered into between the parties in Grijalva v. Shalala, civ. 93-711 (U.S.D.C. Az.), to settle a class action lawsuit. This rule also specifies a Medicare-participating hospital's responsibility for issuing discharge or termination notices under both the original Medicare and M+C programs, amends the Medicare provider agreement regulations with regard to beneficiary notification requirements, and amends M+C enrollee grievance procedures.
Medicare mental health coverage.
Medicare generally covers less than half the cost of mental health-care services. In order for you to best help your clients with mental health-care needs, it is critical to understand Medicare's mental health benefits and gaps. In this brief, we present an overview of mental health coverage and payment policies, including consumers' costs and their rights to appeal denials of payment.
Making the case for insurance TMD reimbursement.
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Monitoring improper Medicare payments. New CMS programs build on OIG methods to report errors.
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Surefire strategies to reduce claim denials.
Denials can be reduced by undertaking some simple steps: Transfer patients automatically from scheduling to pre-registration to have benefits verified and authorizations obtained. Make sure system data fields are large enough to enter all information needed. Track the frequency of denials for noncontracted services and either include them in the contract at renegotiation or discontinue the billing.
Risky business. Big insurers rig the game to avoid covering people likely to file claims.
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Medicare Part B appeals process: a basic roadmap.
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The HMO lawsuit. Is the end in sight?
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Finance issue brief: health care claims payment: prompt payment: year end report-2002.
Since the mid 1990's state legislators and regulators have worked to resolve the complex issue of timely payment of health care claims. They have been challenged with bridging the communication gap between provider and payor and forced to address such base problems as what determines a correctly billed service. As time has progressed it is ever apparent that the completion of payment for services is dependent on many variables, not just simply timely processing of a claim.
Finance issue brief: HMO medical directors: year end report-2002.
Medical directors of managed care organizations have the ultimate responsibility of deciding the treatments for which a health plan will pay. Cognizant of consumer concerns over the power inherent in the position, states are seeking to inject more accountability into the decision-making process. Lawmakers have begun to grapple with whether medical directors should be required to hold a medical license from the state in which they work and, by extension, whether they should be under the jurisdiction of the state medical board.
Finance issue brief: insurer liability: year end report-2002.
When a health plan denies payment for a procedure on grounds that it is not medically necessary or when it refuses a physician-ordered referral to a specialist, has it crossed the line from making an insurance judgment to practicing medicine? If the patient suffers harm as a result of the decision, is the plan liable for medical malpractice? Those were questions 35 states considered in 1999, and at least 32 states are grappling with this year as they seek to respond to physician and patient pressure to curb the power of the managed care industry. Traditionally, health insurers have been protected by state laws banning "the corporate practice of medicine," which means the patient's only recourse is to sue under a "vicarious liability" theory. Now, however, lawmakers are debating legislation to extend the scope of malpractice liability beyond individual practitioners to insurance carriers and plans themselves.