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At least 91 records · Page 5Linked to original sources
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↗
PubMedDate not supplied

Impact of fraudulent claims on health care costs.

The U.S. health care system, considered one of the best in the world for technological sophistication and availability of services, is being seriously threatened by continually escalating costs. Although there are many reasons for this, fraud within the industry accounts for 10 percent of the nation's annual health care bill. By the end of the decade, the fraud factor may cost the industry $160 billion a year. Health insurers and state and government agencies are joining forces to share information and intensify their efforts in the battle against fraud. MetLife's in-house efforts include a specialized unit devoted entirely to the prevention, detection and prosecution of fraud. In 1990 the company's vigilance saved its policyholders over $38 million.

Data Collection↗
PubMed1991

Differential treatment of occupational disease v occupational injury by workers' compensation in Washington State.

Washington State's workers' compensation claims filed in 1984 and followed through 1988 contained 11,356 claims for occupational disease and 178,927 claims for occupational injury. There was a higher rate of rejection (18% v 4%) and resource utilization (14% v 5%) for occupational disease when compared to occupational injury. The factors most predictive of rejection included the specific disease category and the provider frequency of filing. Development of diagnostic guidelines would aid health providers in identifying and properly characterizing occupational diseases.

Accidents, Occupational↗
PubMed1991

Playing the red tape blues.

Explore the source record for details and available documents.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1990

Changing physician behavior: does medical review of Part B Medicare claims make a difference?

This study attempts to determine whether the implementation of mandatory review of Medicare Part B claims for medical necessity has resulted in physicians submitting fewer medically unnecessary claims. After summarizing the literature on the effectiveness of various methods for changing physician practices, we compare the rate at which physicians submitted medically unnecessary claims before and after HCFA imposed mandatory review screens. We find that, consistent with expectations from the literature, the screens are only marginally effective (at best) in reducing the rate at which medically unnecessary claims are submitted. We make some suggestions for lowering this rate.

Cost Control↗
PubMed1995

Responses to a payment policy denying professional charges for diagnostic imaging by nonradiologist physicians.

OBJECTIVE: To assess the impact of a payment policy denying reimbursement for the imaging-related professional services of nonradiologist physicians by comparing the use of and expenditures for diagnostic imaging examinations before and after implementation of the policy. DESIGN: Retrospective economic evaluation of claims and expenditures for diagnostic imaging examinations filed by physicians practicing in the 20 US counties having the greatest number of United Mine Workers of America Health and Retirement Funds (hereafter referred to as Funds) beneficiaries. SETTING: Insurance claims database of Funds beneficiaries, most of whom are elderly and live in rural communities and small towns. INTERVENTION: The January 1, 1993, implementation of a reimbursement policy denying payment of professional claims for diagnostic imaging of nonradiologist physicians. MAIN OUTCOME MEASURES: Numbers and types of eligible claims and Funds payments for diagnostic imaging examinations during the year before and after the intervention, normalized for changes in the number of beneficiaries. RESULTS: Despite the rejection of $811,466 in claims disallowed by the policy, the Funds paid 12% more for diagnostic imaging performed in the 20 counties we studied during 1993 than during 1992. The Funds reimbursed 41% more claims per beneficiary for diagnostic imaging in 1993 than in 1992 (t = -8.03, P < .0001). The absolute number of professional claims per beneficiary increased more than did technical or global claims. CONCLUSIONS: Despite a payment policy designed, in part, to reduce the Funds' imaging-related expenditures, the physicians we studied filed more claims, leading to greater expenditures. An increased number of self-referred technical claims and greater referral to hospital radiology departments likely account for most of the observed increases in utilization and costs.

Cost Control↗
PubMed1997

Medical necessity for right heart catheterization.

Because there are no definitive guidelines for performing right heart catheterizations or controlled clinical trials demonstrating medical benefit, the value and necessity of performing routine right heart catheterizations for coronary artery disease have been questioned. This Texas Medical Foundation Health Care Quality Improvement Program project was designed to ensure medical necessity and proper documentation of right heart catheterization when performed as part of a bilateral procedure. Medicare claims data were used to identify Texas facilities where rates of bilateral catheterizations suggested that right heart catheterizations were being performed routinely. Five facilities were found to have rates of bilateral procedures exceeding 70%. Suggested guidelines for performing right heart catheterizations were prepared by the Texas Medical Association Committee on Cardiovascular Diseases. These guidelines, together with the facility's data on its rate of right heart catheterizations, were presented by the Texas Medical Foundation to the staff of each facility. They were asked to examine their individual facility's procedures for ensuring medical necessity and to develop and implement process improvement plans. Medicare claims data were analyzed to determine the rates of bilateral catheterizations before and after the plans were instituted. The statewide rate of bilateral procedures decreased from 27.2% to 21.3% (p < 0.005). Rate reductions for 4 facilities implementing improvement plans were statistically significant (p < 0.001): at the 1st facility, the rate decreased from 74.3% to 25.0%; at the 2nd, from 85.0% to 21.0%; at the 3rd, from 76.7% to 17.7%; and at the 4th facility, from 85.4% to 42.9%. The rate for the facility not implementing an improvement plan increased from 86.4% to 89.1%. Reductions in rates of bilateral procedures at the 4 facilities suggest that many procedures previously performed were routine and not medically indicated. Presentation of data and practice guidelines to facilities may have contributed to their ability to improve processes.

Cardiac Catheterization↗
PubMed1998

Medicare coding and reimbursement for clinical laboratory services.

Medicare will continue to increase its efforts to cut spending through aggressive review of claims and the use of new fraud and abuse regulations. Providers must be especially careful to provide correct procedure codes that define precisely what services have been provided and accurate diagnosis codes that link those procedures or tests to an appropriate diagnosis. Medicare reimbursement rules for clinical laboratory procedures are explained, including the proper use of procedure and diagnosis codes. Coding and payment for new automated test panels are discussed, as well as the economic consequences of using smaller panels. Medicare coverage requirements, including medical necessity, are described, as well as the proper use of advance beneficiary notices and the Medicare appeals process.

Abstracting and Indexing↗