SEARCH · Search PubMed
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.
An evaluation of onsite concurrent review over and above the effects of Aetna's precertification program demonstrated reduced utilization and expenses, especially for ancillary services, and no adverse effects on rates of medical complications.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Hospital utilization review (UR) has expanded rapidly in recent years and is now widely used by private payers as an approach to cost containment. This article reports estimates of the effects of UR on hospital utilization and medical expenditures based on a covariance estimation procedure. Claims data on 223 privately insured groups were analyzed covering a three-year period, 1984 through 1986. UR was associated with an approximate 12 percent decrease in admissions, a 14 percent decrease in hospital routine expenditures, and a 6 percent decrease in total medical expenditures. UR appears to reduce expenditures mainly by reducing admissions; hospital inpatient expenditures per admission were unaffected by the review activity. Analysis showed the effect of UR to have been greatest during the quarters immediately following implementation of the review activity. This finding underscores the need to analyze longitudinal data having sufficient time-series observations to obtain reliable estimates of long-term program impact. The analysis described here offers a computationally efficient alternative specification to the standard fixed-effects approach for analyzing pooled data, and is especially useful when the number of cross-section units is large.
STUDY OBJECTIVES: We compare the results of a provider "self-adjudicating" outpatient emergency department claims using a "presenting symptom-based" system with the managed care organization (MCO) adjudicating the claims using a "final diagnosis-based" system. METHODS: All outpatient visits from one MCO to an urban, university hospital between January 1, 1998, and February 28, 1999, were included. Each record was reviewed by 2 methods to determine whether the visit qualified for payment under the MCO's benefit structure. Under the provider adjudication, symptom-based system, all visits with nursing triage levels of immediate/emergency were approved automatically. Those with triage levels of delayed/nonurgent were reviewed by an emergency physician and approved if, in the physician's opinion, the presenting symptoms met the emergency criteria under the District of Columbia's Access to Emergency Services Act. A second claims review, blinded to the first, was performed with the diagnosis-based system used by the MCO before approval of the prudent layperson standard. This review divided the records into "approve," "deny," and "suspend" categories according to the discharge International Classification of Diseases, ninth revision code. The results of the 2 reviews were compared. RESULTS: We reviewed 1,830 records; 836 (46%) cases were triaged as immediate/emergency and 994 (54%) as delayed/nonurgent. Of the 994 delayed/nonurgent visits, physician review determined that 607 (61%) met the prudent layperson standard and 387 (39%) did not. Overall, the provider self-adjudication system determined that 1,443 (78.8%) of the 1,830 visits should be approved for insurance coverage. The MCO's system approved 966 (53%), denied 335 (18%), and suspended 529 (29%). Provider self-adjudication using a symptom-based system resulted in the immediate approval of 1,443 (77.8%) visits compared with 966 (52.7%) by a diagnosis-based system (P <.001). Excluding the 529 suspended claims, McNemar's statistical testing of 1,302 records failed to demonstrate the equivalence of the 2 systems (P <. 001). CONCLUSION: Compared with the standard ED claims review process used by the managed care industry, provider self-adjudication using a symptom-based system approves a greater proportion of visits, avoids rejection of many ED visits, and identifies many nonemergency visits that mistakenly appear to be emergencies. The possibility of providers and MCOs working together to adjudicate outpatient ED claims should be explored.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
OBJECTIVE: To develop Clinical Risk Groups (CRGs), a claims-based classification system for risk adjustment that assigns each individual to a single mutually exclusive risk group based on historical clinical and demographic characteristics to predict future use of healthcare resources. STUDY DESIGN/DATA SOURCES: We developed CRGs through a highly iterative process of extensive clinical hypothesis generation followed by evaluation and verification with computerized claims-based databases containing inpatient and ambulatory information from 3 sources: a 5% sample of Medicare enrollees for years 1991-1994, a privately insured population enrolled during the same time period, and a Medicaid population with 2 years of data. RESULTS: We created a system of 269 hierarchically ranked, mutually exclusive base-risk groups (Base CRGs) based on the presence of chronic diseases and combinations of chronic diseases. We subdivided Base CRGs by levels of severity of illness to yield a total of 1075 groups. We evaluated the predictive performance of the full CRG model with R2 calculations and obtained values of 11.88 for a Medicare validation data set without adjusting predicted payments for persons who died in the prediction year, and 10.88 with a death adjustment. A concurrent analysis, using diagnostic information from the same year as expenditures, yielded an R2 of 42.75 for 1994. CONCLUSION: CRGs performance is comparable to other risk adjustment systems. CRGs have the potential to provide risk adjustment for capitated payment systems and management systems that support care pathways and case management.
Pharmaceutical insurance applies to drugs which are approved by Swedish licensing authorities and are marketing in Sweden. This paper reviews the pharmaceutical insurance.
Explore the source record for details and available documents.
The examination of claims settlement in life assurance usually begins when police investigation is finished. During the acute phase of police investigation there is very rarely contact between the police and the life insurance company concerned. The advantages of early cooperation are demonstrated by two case reports. Immediate communication during the first four days after death initially helps the police investigators; later the life insurance company profits from the accelerated examination of the insured event.
Explore the source record for details and available documents.
Physicians recognize that there is a certain amount of waste and inefficiency in the current health care delivery system. They also realize that everyone stands to gain if the areas of waste can be identified and eliminated. Statistics consistently reveal that a small percentage of providers and patients are responsible for a very large percentage of inappropriate care. A properly structured utilization review program is a reasonable way to rid the delivery system of this waste.
This interim rule implements provisions of section 4401 of the Omnibus Budget Reconciliation Act of 1990 by specifying requirements for a Drug Use Review program, including the establishment of Drug Use Review Boards, and for an Electronic Claims Management system for outpatient drugs.
Explore the source record for details and available documents.