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PubMedDate not supplied

Prompt pay statutes for physicians' billing claims: an imperfect remedy for a systemic problem.

Physicians are losing millions of dollars per year from delayed and wrongfully denied claims. Class actions provide for certain forms of prospective relief but do not cover physician losses from payers' vexatious conduct. This article examines the effect of state prompt pay statutes and recent amendments to ERISA regulations on curtailing payer payment abuses. The article discusses the strengths and weaknesses of the statutes, as well as strategies for effectively using the statutes for the benefit of physicians.

Accounts Payable and Receivable↗
PubMed2005

Exploring the potential link between Medicaid access restrictions, physician location, and health disparities.

OBJECTIVE: To determine whether a given doctor treating Medicaid patients is likely to practice in a predominantly minority area, and whether a minority patient is likely to be treated by a physician who is heavily influenced by Medicaid policy decisions. STUDY DESIGN: Retrospective pharmacy claims database analysis combined with zip-5-level demographic analysis. METHODS: Data extracted from a large prescription claims database were used to categorize all active prescribers in the United States by the proportion of prescription claims paid by state Medicaid programs from May 31, 2003, to April 30, 2004. US Census data from 2000 were used to assess the ethnic composition of each physician's zip code. Descriptive analyses were conducted to explore any associations between zip code racial composition and proportion of prescriber prescription claims adjudicated by state Medicaid programs. RESULTS: Physicians with more than 75% of their prescriptions adjudicated through Medicaid versus those with fewer than 1% of their prescriptions adjudicated through Medicaid practiced in zip codes that were 47% versus 24% nonwhite, respectively. Residents in Medicaid-intense zip codes were 59% nonwhite versus 31% nonwhite in the nation as a whole. CONCLUSION: Nonwhite residents are much more likely than white residents to live in a zip code where Medicaid prescribing rules will affect their physician. Any legislation-induced changes in prescribing patterns seem likely to disproportionately impact both Medicaid and non-Medicaid minority residents in these areas.

Drug Prescriptions↗
PubMed2005

Medicare program; durable medical equipment regional carrier service areas and related matters. Final rule.

This final rule provides a mechanism for us to expeditiously make changes to the durable medical equipment regional carrier (DMERC) service area boundaries without notice and comment rulemaking. Through this mechanism, we can change the geographical boundaries served by the regional contractors that process durable medical equipment claims through issuance of a Federal Register notice and make other minor changes in the contract administration of the DMERCs. The mechanism provides a method for increasing or decreasing the number of DMERCs, changing the boundaries of DMERCs based on criteria other than the boundaries of the Common Working File sectors, and awarding new contractors to perform statistical analysis or maintain the national supplier clearinghouse. We will publish these changes and their justifications in a Federal Register notice, rather than through notice and comment rulemaking. Although we may change the number and configuration of regional carriers, we are not altering the criteria and factors that we use in awarding contracts. Through this final rule, we are improving the contracting process so that we can swiftly meet the challenges of the changing healthcare industry and address the changing needs of beneficiaries, suppliers, and the Medicare program.

Catchment Area, Health↗
PubMed2004

"Medical necessity" determinations--a continuing healthcare policy problem.

To promote an understanding of the implications of current structures and processes for medical necessity determinations that affect everyone, directly or indirectly, the American Health Lawyers Association will devote its biannual Public Interest Colloquium (to be held in February 2005) to the topic. In preparation for the colloquium, the author summarizes the history and current importance of the topic, identifies stakeholders in the system and their interests, and sets forth a preliminary list of issues to be considered by the colloquium participants, focusing on potential elements of an ideal system for making medical necessity determinations.

Diagnostic Services↗
PubMed2005

Medicare program: changes to the Medicare claims appeal procedures. Interim final rule with comment period.

Medicare beneficiaries and, under certain circumstances, providers and suppliers of health care services, can appeal adverse determinations regarding claims for benefits under Medicare Part A and Part B under sections 1869 and 1879 of the Social Security Act (the Act). Section 521 of the Medicare, Medicaid, and SCHIP Benefits Act of 2000 (BIPA) amended section 1869 of the Act to provide for significant changes to the Medicare claims appeal procedures. This interim final rule responds to comments on the November 15, 2002 proposed rule regarding changes to these appeal procedures, establishes the implementing regulations, and explains how the new procedures will be implemented. It also sets forth provisions that are needed to implement the new statutory requirements enacted in Title IX of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).

Child↗
PubMedDate not supplied

Maximizing reimbursement by appealing claim denials.

Providers continue to lose millions of dollars from payers' abusive practices. An immediate way to increase reimbursement rates is to know and understand effective administrative appeal processes. These processes are usually defined by contract or by statute. Recent amendments to regulations governing ERISA are helpful to providers.

Contracts↗
PubMedDate not supplied

Carotid artery stenting: anatomy of a Medicare coverage decision.

The Centers for Medicare and Medicaid Services has made an important reimbursement decision regarding carotid artery stenting for patients at high risk for carotid endarterectomy surgery. This article will identify the carotid coverage questions and process as a case study of the issues that the Centers and stakeholders can face regarding complex new technologies, as well as the questions for carotid artery stenting and other new technologies that the process raises for your hospital.

Carotid Arteries↗
PubMed2005

Extension of the expiration date for several body system listings. Final rule.

We use the Listing of Impairments (the listings) at the third step of the sequential evaluation process when we evaluate your claim for benefits based on disability under title II and title XVI of the Social Security Act (the Act). This final rule extends until July 3, 2006, the date on which listings for four body systems will no longer be effective and extends until July 2, 2007, the date on which the listings for eight body systems will no longer be effective. Other than extending the date during which the listings will be effective, we have made no revisions to the listings; they remain the same as they now appear in the Code of Federal Regulations. This extension will ensure that we continue to have the medical evaluation criteria in the listings to adjudicate disability claims in these body systems at step three of the sequential evaluation process.

Eligibility Determination↗