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PubMed2005

Medicare introduces new appeals process.

This article addresses the wholly reformed appeals process in a broad based manner. It describes only the basic structure of a new appeals system. Appealing parties should be careful to learn in more detail the new system prior to pursuing an appeal. While many appeals can be pursued without legal counsel, it may be advisable to initially utilize an attorney for appeals until one becomes familiar and comfortable with the new process. Despite any of the shortcomings discussed above or new obstacles created by CMS in the rules, the appeals process should continue to be a very useful mechanism to successfully reverse inappropriate claim denials.

Aged↗
PubMed2005

Impact of 3-tier pharmacy benefit design and increased consumer cost-sharing on drug utilization.

OBJECTIVE: To estimate responsiveness of prescription demand within 9 therapeutic classes to increased cost-sharing compared with constant cost-sharing. STUDY DESIGN: Retrospective prescription claims analysis. METHODS: Between 1999 and 2001, 3 benefit plans changed from a 2-tier to a 3-tier design (cases); 1 plan kept a 2-tier design (controls). Study subjects needed 24 months of continuous coverage and a prescription filled < OR = 3 months before the benefit change for a nonsteroidal anti-inflammatory agent (NSAID), a cyclooxygenase (COX-2) inhibitor, a selective serotonin reuptake inhibitor (SSRI), a tricyclic antidepressant (TCA), an angiotensin-converting enzyme (ACE) inhibitor, a calcium-channel blocker (CCB), an angiotensin-receptor blocker (ARB), a statin, or a triptan. Changes in use were compared with the Wilcoxon signed rank test. Elasticity of demand among cases was calculated. RESULTS: Generally, medication possession ratios decreased for cases and increased for controls between 1999 and 2000. Switch rates increased for cases and decreased for controls for all classes but CCBs. Switches to lower copayments for ACE inhibitors, statins, and triptans occurred more often for cases. Discontinuation-rate changes for cases were 2 to 8 times those for controls. Generic-substitution rates depended on availability and initial generic utilization. Elasticity of demand for drugs was generally low, -0.16 to -0.10, for asymptomatic conditions (ACE inhibitors, ARBs, CCBs, statins), and moderate, -0.60 to -0.24, for symptomatic conditions (COX-2 inhibitors, NSAIDs, triptans, SSRIs). CONCLUSION: Use of retail prescription medications within 9 specific therapeutic classes decreased as copayment increased. Demand for pharmaceuticals was relatively inelastic with these copayment increases.

Cost Sharing↗
PubMed2005

Making them pay.

Explore the source record for details and available documents.

Humans↗
PubMed2006

Who will be denied Medicare prescription drug subsidies because of the asset test?

OBJECTIVE: To determine the number and characteristics of Medicare beneficiaries who will be excluded from low-income prescription drug subsidies because they do not qualify under an asset test. STUDY DESIGN: Cross-sectional, using the US Census Bureau's Survey of Income and Program Participation (SIPP); results were based on interviews occurring between October 2002 and January 2003. The sample included 9278 Medicare beneficiaries, 2929 with incomes below 150% of the federal poverty level (FPL). METHODS: Using SIPP, each sample member's income was compared to the FPL. Income was adjusted to include only liquid assets and primary residences. The number of individuals excluded by the asset test and their characteristics and types of assets responsible were calculated. RESULTS: Of 13.97 million noninstitutionalized Medicare beneficiaries, 2.37 million (17%) with low incomes would be excluded from subsidized drug coverage due to the asset test. Compared to higher-income beneficiaries, the excluded individuals tended to be older, female, widowed, and living alone. Almost half of their assets were checking and savings accounts. Half of the individuals failing the test had assets less than 35,000 dollars above the allowing thresholds. CONCLUSIONS: Widows are disproportionately affected by the asset test. When a husband dies, income plummets but accumulated assets often exceed those allowed under Medicare legislation. During their working years Americans are encouraged to save for retirement, but by accumulating modest amounts of assets, these same people often will then not qualify for low-income drug subsidies. Modifying or eliminating the asset test would help protect individuals disadvantaged by low incomes who have modest amounts of asset holdings.

Aged↗
PubMed2006

[Treatment of temporomandibular disorders in general practice. A survey in view of insurance claims].

In the eighth decade of the last century, about 3.5% of Dutch men and about 6% of Dutch women reported temporomandibular disorders. In 5% of the Dutch population temporomandibular disorders were diagnosed. It is unknown how many persons are seeking treatment for temporomandibular complaints. The aim of the present study was determining for how many persons and at which age of these persons treatments of temporomandibular disorders in general practices were reimbursed by an insurance company. On the basis of the yearly number of reimbursements by this insurance company, the yearly number of treatments of the Dutch population as a whole was estimated. The estimation was 0.87 treatments per 1.000 inhabitants, which figure was substantial lower as could be expected on the basis of the outcome of epidemiologic research projects. Within the limitations of this explorative study, a careful conclusion could be that only few treatments for temporomandibular disorders are charged by general practitioners. Probably, they are focussing on consultation and diagnosing, and not on treating the disease themselves.

Fees, Dental↗