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At least 649 records · Page 36Linked to original sources
PubMed2003

Getting a handle on health fund finances: a comprehensive but practical approach.

Multiemployer health funds are being hammered from several directions. While it is difficult to find a silver lining in the situation, plan sponsors are far from helpless. They should immediately begin to take concrete steps to help stabilize plan costs in order to be able to continue to offer their members meaningful health coverage.

Cost Control↗
PubMed2003

Identifying barriers to billing compliance.

Programs designed toward the control of health care fraud are leading to increasingly aggressive enforcement and prosecutorial efforts by federal regulators, related to over-reimbursement for service providers. Greater penalties for fraudulent practices have been touted as an effective deterrent to practices that encourage, or fail to prevent, incorrect claims for reimbursement. In such a context, this study sought to examine the extent of compliance management barriers through a national survey of all accredited US health information managers, examining likely barriers to payment of health care claims. Using data from a series of surveys on the stated compliance actions of more than 16,000 health care managers, we find that the publication and dissemination of compliance enforcement regulations had a significant effect on the reduction of fraud. Results further suggest that significant non-adoption of proper billing compliance measures continues to occur, despite the existence of counter-fraud prosecution risk designed to enforce proper compliance. Finally, we identify benchmarks of compliance management and show how they vary across demographic, practice setting, and market characteristics. We find significant variation in influence across practice settings and managed care markets. While greater publicity related to proper billing procedures generally leads to greater compliance awareness, this trend may have created pockets of "institutional non-compliance," which result in an increase in the prevalence of non-compliant management actions. As a more general proposition, we find that it is not sufficient to consider compliance actions independent of institutional or industry-wide influences.

Data Collection↗
PubMedDate not supplied

[Remarks on operative regulations relating to decision making about inability to work in pension cases].

In years 1996 and 1997 both the Pension Act and the Social Insurance Act were changed in Poland and as a consequence of this, all the regulations relating to decision making about the inability to work. Having suppressed the so-called disability groups, such terms as permanent or temporary inability to work were introduced. Medical boards deciding on disability were replaced by predicative physicians working for the Social Insurance Department. Recently a rise in number of cases relative to the verification of the decisions passed by the SID and sent by either employer or Social Insurance Departments of district courts to the Department of Forensic Medicine Silesian Academy in Katowice has been observed. The authors have tried to analyse the cause of a rise in the number of appeals to a decision of the SID submitted by the insured.

Disability Evaluation↗
PubMed2003

Risk factors for ill health insurance claims.

OBJECTIVES: This study examined the information available at application for income protection insurance, to determine if any factors were predictive of a claim. The strength and significance of such factors were assessed and a predictive model was developed. BACKGROUND: The factors underlying life assurance risks are well known, but this is not the case for income protection insurance. For accurate underwriting of income protection insurance, it is important to know what information available at application has power to predict a claim. Improving the scientific accuracy of underwriting is good business practice, as well as answering the demands of disability legislation. METHODS: We studied all data available at application for 959 current claimants and 1417 non-claimants, using a case-control study design. Information included applicants' description of their occupation, marital status, build and habits, plus a questionnaire asking about their personal health. For some applicants medical reports were available as well. Information was transcribed onto a database, and univariate and multivariate analyses were performed. A predictive scoring system was established and its performance measured by receiver operating characteristic curves. RESULTS: Significant associations with claiming were found for many variables, including age (odds-ratio 1.04, p < 0.001), height (0.11, p = 0.03), smoking (2.10, p < 0.001), abstinence from alcohol (1.56, p = 0.01), recent medical advice (1.34, p = 0.06), and having had a lower gastrointestinal disorder (1.51, p = 0.04). Using all the information from the application, a predictive model was constructed. This model had good predictive power with an area under the receiver operating characteristic curve of 72%. CONCLUSIONS: Classical underwriting factors were generally shown to have predictive power for income protection insurance. The predictive scoring strengthens the scientific basis for underwriting and could be developed to simplify and expedite the underwriting process.

Actuarial Analysis↗
PubMed2003

Exploring out-patient behaviors in claim database: a case study using association rules.

Patient behaviors are affected by so many factors that makes it is not easy to describe by simple measures. Our approach bases on finding association rules, which is widely used in marketing to identify their customers. We found rules describing complex patient behavior from huge claim dataset and we grouped them into several groups for a better understanding.

Health Services↗