Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “Insurance Claim Review”

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.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 865 records · Page 48Linked to original sources
PubMed1998

Risk management and the claims process.

This article explores certain risk management techniques and the role these techniques play in the investigation and evaluation of claims. The claims experience of one carrier, Medical Liability Mutual Insurance Co., is provided. A general overview of the elements involved in a claims investigation is provided.

Dental Records↗
PubMed1998

[The concept of "compensation neurosis" in psychiatric expertise].

The concept of "compensation neurosis" in German civil and social law is subject to controversial considerations. Despite long-standing discussions it still remains unclear, whether "compensation neurosis" means a genuine psychiatric disorder, or whether it merely stands for a person who claims unjustified demands after having suffered a traumatic situation. The term "compensation neurosis" therefore is not to be used as a diagnosis in psychiatric expertise. Diagnosis should be made according to ICD-10 or DSM-IV-criteria. The patient's psychic and psychosocial impairments must be related to the severity of his trauma and to the history of his pretraumatic and posttraumatic psychic symptoms. To help estimate posttraumatic financial compensation a complete psychopathological and psychodynamic examination with detailed assessments of individual psychic impairments is essential in psychiatric expertise.

Humans↗
PubMed1998

[Self-mutilating hand and finger injuries among physicians suspected of insurance fraud].

27 cases of questionable self-mutilation among physicians (concerning finger and hand injuries) were analyzed retrospectively. The evaluation based on files of the insurance companies, reconstructive examinations and experimental investigations. Three typical cases are described in detail, the "victims" were suspected to have committed a special kind of fraud in order to claim financial compensation from their accident-insurance companies; the contract included special invalidity payments for finger injures (so-called "Gliedertaxe"). Many of these physicians had worked in the surgical field: apart from one 38-year-old female all of them were males, aged between 41 and 66 years. The mutilating instruments were often circular saws, sometimes chain saws and a great variety of other tools, for example hatchet, big scissors and other sharp instruments. By means of forensic-medical expertise and criminalistic investigations the insurance companies were able to demonstrate clearly that the amputation was voluntarily self-inflicted. The forensic-medical argumentation concerning intentional self-mutilation included the so-called execution position of the finger, the injury pattern, the investigations of blood stains and ergonometric aspects.

Adult↗
PubMed1988

Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors.

Fourteen cases of sudden cardiac arrest in healthy patients who received spinal anesthesia were discovered in a preliminary review of 900 closed insurance claims for major anesthetic mishaps. All patients were resuscitated from the intraoperative cardiac arrest, but six suffered such severe neurologic injury that they died in hospital. Of the eight survivors, only one exhibited sufficient neurologic recovery to allow independence in daily self-care. In view of the unexpected nature of the cardiac arrests, as well as the ultimate severity of injury, these cases were analyzed in detail to determine whether there were recurring patterns of management that may have contributed to the occurrence or outcome of these anesthetic mishaps. Two patterns were identified. The first was the intraoperative use of sufficient sedation to produce a comfortable-appearing, sleep-like state in which there was no spontaneous verbalization. Cyanosis frequently heralded the onset of cardiac arrest in patients exhibiting this degree of sedation, suggesting that unappreciated respiratory insufficiency may have played an important role. The second pattern appeared to be an inadequate appreciation of the interaction between sympathetic blockade during high spinal anesthesia and the mechanisms of cardiopulmonary resuscitation. Prompt augmentation of central venous filing through the use of a potent alpha-agonist and positional change might have improved organ perfusion, shortened the duration of cardiac arrest, and lessened the degree of neurologic damage.

Adult↗
PubMed2006

Analysis of surgical errors in closed malpractice claims at 4 liability insurers.

BACKGROUND: The relative importance of the different factors that cause surgical error is unknown. Malpractice claim file analysis may help to identify leading causes of surgical error and identify opportunities for prevention. METHODS: We retrospectively reviewed 444 closed malpractice claims, from 4 malpractice liability insurers, in which patients alleged a surgical error. Surgeon-reviewers examined the litigation file and medical record to determine whether an injury attributable to surgical error had occurred and, if so, what factors contributed. Detailed descriptive information concerning etiology and outcome was recorded. RESULTS: Reviewers identified surgical errors that resulted in patient injury in 258 of the 444 (58%) claims. Sixty-five percent of these cases involved significant or major injury; 23% involved death. In most cases (75%), errors occurred in intraoperative care; 25% in preoperative care; 35% in postoperative care. Thirty-one percent of the cases had errors occurring during multiple phases of care; in 62%, more than 1 clinician played a contributory role. Systems factors contributed to error in 82% of cases. The leading system factors were inexperience/lack of technical competence (41%) and communication breakdown (24%). Cases with technical errors (54%) were more likely than those without technical errors to involve errors in multiple phases of care (36% vs 24%, P = .03), multiple personnel (83% vs 63%, P < .001), lack of technical competence/knowledge (51% vs 29%, P < .001) and patient-related factors (54% vs 33%, P = .001). CONCLUSIONS: Systems factors play a critical role in most surgical errors, including technical errors. Closed claims analysis can help to identify priority areas for intervening to reduce errors.

Adolescent↗
PubMed1989

Role of monitoring devices in prevention of anesthetic mishaps: a closed claims analysis.

Anesthesiologist-reviewers examined 1,175 anesthetic-related closed malpractice claims from 17 professional liability insurance companies. The claims were filed between 1974 and 1988. The reviewers were asked to determine if the negative outcome was preventable by proper use of additional monitoring devices available at the time of the review even if not available at the time the incident occurred, and if so, which devices could have been preventative. In 1,097 cases sufficient information was available to make a judgment regarding preventability of the morbidity or mortality by application of additional monitoring devices. It was determined that 31.5% of the negative outcomes could have been prevented by application of additional monitors. Using the insurance industry's scale of 0 (no injury) to 9 (death), the median severity of injury for incidents deemed preventable was 9 compared with 5 for those deemed not preventable (P less than 0.01, scale detailed in text). The severity of injury scores were the same for preventable mishaps occurring during regional or general anesthesia, suggesting that additional monitoring devices may be equally efficacious in preventing serious negative outcomes during either regional or general anesthesia. The judgements or settlements of the incidents judged preventable by additional monitoring were 11 times more costly (P less than 0.01) than those mishaps not judged preventable. The monitors determined by the reviewers to be most useful in mishap prevention were pulse oximetry plus capnometry. Applied together, these two technologies were considered potentially preventative in 93% of the preventable mishaps.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia↗
PubMed2000

[Complaints against radiologists in Italy].

INTRODUCTION: Legal claims against radiologists are a relevant phenomenon also in our country and represent an increasing risk for a radiologist's professional activity. MATERIAL AND METHODS: We reviewed the 1993-1998 insurance claims against Italian radiologists. We found 259 claims subdivided by type into: 1) misdiagnosis; 2) complications of the examination; 3) missed referral for further examinations/treatment; 4) (non)ionizing radiation treatment; 5) slip-and-fall injuries; 6) miscellaneous cases. All claims were reviewed anonymously. RESULTS AND DISCUSSION: Most of the 259 malpractice claims were filed late after the event, which makes the actual incidence of the phenomenon difficult to evaluate. Nevertheless the incidence of malpractice claims can be estimated at 32 per thousand people a year, meaning that an Italian radiologist's risk of being sued by a patient at least once in his/her professional life exceeds 1. Alleged misdiagnosis was the most frequent claim category. Missed bone abnormalities of any type, including fractures, dislocations, malignant lesions and other nonspecific conditions accounted for 52.9% of cases. Missed abnormalities on breast and chest examinations accounted for 17.5% and 15.3%, respectively. Within this claim category, missed breast lesions exhibited the most increasing trend. Alleged complications from radiological examinations accounted for 20% of cases and mostly involved i.v. contrast agent administration, interventional procedures and barium enema. Slip-and-fall injuries, where the patients falls off the examination table, slips on the floor, bumps into a piece of equipment and so on, accounted for 7% of cases. Missed referral to further examinations accounted for 1.5% only. Finally, radiologists were frequently sued as one of many defendants, together with medical/surgical doctors, in case of patient's death, in 20% of all cases. CONCLUSIONS: Italian radiologists currently run the same risk of being sued for malpractice as their American colleagues. Strict compliance with radiological standards is recommended to try to decrease the risk and to obviate litigation.

Diagnostic Errors↗
PubMed2000

Results of a pilot study reviewing dermatitis claims submitted to the Ontario Workplace Safety and Insurance Board.

BACKGROUND: Workers who develop occupational skin disease are often eligible for workers' compensation benefits; however, there is little known about the decision-making process for adjudicating claims submitted for work-related skin problems. OBJECTIVE: The objective of this pilot study was to test a file abstraction instrument and determine the nature of information that was available for decision-making. METHODS: Files submitted to the Ontario Workplace Safety and Insurance Board (WSIB) in 1995 for dermatitis were identified. The last 51 files were abstracted to collect information concerning demographics, physicians seen, information available in the claim file for decision making, as well as type of claim and outcome of the claim. RESULTS: Approximately 70% of the claims were "no-lost-time" and one-third of total claims were accepted for compensation. Although there was reasonable information related to the clinical status, most claims had no information that related to workplace issues such as exposures or association with work. Claims that were for lost time or were accepted had more information available. CONCLUSIONS: The pilot study has demonstrated that there is a lack of information related to workplace issues that would be important in decision-making. The study will be extended to examine the entire year's claims in order to develop a strategy to enhance the understanding of the WSIB and providers regarding the information necessary for decision-making and to determine methods to facilitate its collection.

Adult↗
PubMed1991

Structure, process, effectiveness and efficiency of the check and review system in Japan's health insurance.

Keeping medical costs at an adequate and affordable level cannot be realized by the efforts of medical facilities alone, nor by the revision of fee schedules and price schedules of drugs in Japan's health insurance systems. Rationalization and improvement in the efficiency of all of the systems, including the various insurance organizations and the organizations for review and payment, are imperative. This paper first examines the system of review and payment for insurance claims under Japan's health insurance systems with emphasis on three main points, namely (1) qualification checks, (2) check and review of insurance claims and (3) computerization of the screening process. Relevant issues facing the check and review system are then discussed.

Cost Control↗
PubMed1990

Liability for medical record disclosure is real but rare.

The most recent public concern for patient confidentiality has centered on the medical records of AIDS patients. However, a new confidentiality concern is the liability of the self-insured hospital that reviews medical claims internally. Also, the sometimes conflicting demands of protecting patient confidentiality and being reimbursed in a timely fashion are setting off sparks between the medical records department and the business office.

Confidentiality↗
PubMedDate not supplied

Using insurance claims data and medical record reviews to assess the quality of medical care.

This article examines the possibilities and limitations of using computerized insurance claims and outpatient medical records to evaluate a Medicaid managed care program. The quality of medical care delivered to enrollees 1 1/2 years into the MassHealth managed care program's operation is discussed in the context of an evaluation that was conducted by the University of Massachusetts-Boston's McCormack Institute in 1993. Study results suggest that these two data sources offer adequate information to determine the quality level of primary and preventive services and lead to further suggestions for evaluating care.

Adult↗