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PubMed2000

Second opinions on coverage.

It's the main complaint about managed care: Doctor and patient agree on a specific treatment, but the HMO refuses to pay for it. Until recently, the only remedy available to patients was long and costly lawsuits. Now, patients and health plans are finding that external review boards--panels of independent experts--offer an inexpensive and fair alternative for resolving such disputes.

Conflict of Interest↗
PubMed2000

[Are you prescribing fatal hormones? Bremen professor accuses physicians with unsubstantiated claims].

The present study uses arbitrary projections based on non-representative local polls of women insured by the AOK (an insurance carrier) to construct a fictitious Pan-German data base, which is then used to make pronouncements on the hormone exposure, hysterectomy status and the prevalence of estrogen monotherapy in non-hysterectomied women in all the German Bundesländern (States). Using the data of the Saarland cancer registry the yearly incidence of approximately 42,000 mammary carcinomas (MC) and approximately 8700 endometrial carcinomas (EC) were extrapolated to the whole of Germany. Relative risks obtained from US literature were arbitrarily used as factors for calculations showing a yearly attributive risk of approximately 5000 MC and approximately 3000 EC due to the use of exogenous sex hormones. Although the numerical details of the calculations are not given, the information the authors provide on the acquisition and processing of the data--as also the interpretation of the results--leaves no room for doubt that here the minimum formal, content-related and methodological standards required of epidemiological studies have not been met. Since the quality of the basic data makes the results, even as "preliminary estimations" [2], unacceptable, they merely add to the already existing contradictory and inconsistent data material.

Bias↗
PubMedDate not supplied

"We didn't get the claim," and other payer excuses.

How many times have you heard from a third-party payer, "we don't have the claim"? Is it only the health insurance industry that has problems receiving its mail and electronic transmissions? Rather than spend time beating up on the payers, the author provides constructive and proactive approaches to help identify why claims fall into a black hole and how to avoid pitfalls.

Insurance Carriers↗