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PubMed2006

Jurisdictional issues related to PRRB appeals.

Protecting your right to appeal a final determination on program reimbursement requires a knowledge of the mandatory criteria that must be met as well as the jurisdictional issues related to Provider Reimbursement Review Board appeals. Common jurisdictional issues include: Final determination. Provider satisfaction with a final determination. Reopenings. Adding issues to an appeal. Expedited judicial review.

Financial Management, Hospital↗
PubMed1993

An integrated approach to managed care contracting.

Managed care plans make up an increasing share of today's hospital payer mix. As a result, it is important for hospitals to negotiate the best possible managed care contract terms in order to minimize risk and maximize opportunity. This article presents a six-step "closed loop" approach to managed care contracting, showing how hospitals can integrate--through their information systems--the strategic, financial, and patient care processes that are part of the managed care cycle.

Accounts Payable and Receivable↗
PubMed2001

Effect of sumatriptan on health care resource use among patients with migraine.

Previous investigations examining health care resource utilization in patient populations have shown patients with migraine to consume significantly higher health care resources compared with individuals without migraine. The purpose of this study was to compare health care resource and narcotic use in migraineurs prescribed sumatriptan (oral, subcutaneous, or nasal) with those not prescribed sumatriptan.

Adult↗
PubMedDate not supplied

Risk management lessons from a review of 168 cataract surgery claims.

One hundred sixty-eight closed claims involving cataract procedures reported to Ophthalmic Mutual Insurance Company (OMIC) over a 10-year period were evaluated. Indemnity payments totaling more than $3 million were made in 37 cases. These 37 cases represented only 7% of all OMIC claims, but their total indemnity payment represented 24% of the total indemnity paid by OMIC during the 10-year period.

Cataract Extraction↗
PubMed2003

Persistence with COX-2 inhibitors in managed care: an analysis of claims data.

Drug tolerability strongly influences patients' persistence with treatment. In this study, patterns of medication persistence with cyclooxygenase 2 (COX-2)-specific inhibitors and nonspecific nonsteroidal anti-inflammatory drugs (NSAIDs) were compared in a managed care setting. Pharmacy, enrollment, and medical claims data from 19 health plans were used to match subjects newly treated with celecoxib, rofecoxib, ibuprofen, naproxen, or diclofenac between July 1, 1999 and June 30, 2000. By using multiple regression analysis, users of COX-2-specific inhibitors were found to be 56.8% less likely to discontinue medication use and 60.3% less likely to switch treatment than were users of nonspecific NSAIDs (P < .001). Celecoxib users were 4.6% less likely to discontinue treatment than were rofecoxib users (P < .001). The greater persistence observed among users of COX-2 inhibitors might reflect improved treatment efficacy and patient satisfaction.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2006

Utilization and drug cost outcomes of a step-therapy edit for generic antidepressants in an HMO in an integrated health system.

OBJECTIVE: Antidepressants do not differ significantly in their ability to treat depression. Excluding the tricyclic antidepressants (TCAs), these drugs also do not differ significantly in their incidence of adverse events. Therefore, the initial choice of antidepressant medication should be based, in part, on cost. The objective of this study was to evaluate the impact on utilization and costs of a generic steptherapy edit for antidepressant drugs excluding TCAs in a health maintenance organization (HMO) in an integrated health system (IHS). METHODS: The pharmacy department of the 440,000-member HMO in an IHS collaborated with the Behavioral Health Clinical Program to design an intervention that required generic antidepressants as first-line pharmacotherapy. Under the GenericStart! Program, a brand-name antidepressant was covered only after trial with a generic antidepressant, excluding TCAs. A step-therapy edit was added to the pharmacy claims processing system on January 1, 2005. All new starts, defined as members with no claims history of antidepressant treatment within the preceding 6 months, were required to use a generic antidepressant. The member copayment was waived for the first prescription. All generic antidepressants were in tier 1 of the drug formulary, with an average copayment of $5 to $10. All brand-name antidepressants were in either tier 2 (preferred brand), with an average copayment of $20 to $25 or 25% coinsurance, or tier 3 (nonformulary brand), with an average copayment of $40 to $45 or 50% coinsurance. Pharmacy claims data from a national pharmacy benefit manager (PBM) without interventions for antidepressants in 2004 or 2005 were used for the comparison group. RESULTS: The generic antidepressant dispensing rate increased by 20 points (32.5% to 52.5%) in the intervention group but only 7.4 points (24.9% to 32.3%) in the comparison group in 2005 compared with 2004. The principal measure of antidepressant drug cost per day of therapy in the intervention group decreased by 11.7% (from $2.40 to $2.12) in 2005 compared with 2004 versus a 2.7% decrease (from $2.60 to $2.53) in the comparison group (P <0.001). Days of antidepressant drug therapy per member per month (PMPM) dropped by 1.5% (from 1.74 to 1.71) in the intervention group versus a decrease of 5.0% (from 1.37 to 1.30) in the comparison group in 2005 compared with 2004. The combination of change in drug cost and utilization resulted in a 13.0% decrease in antidepressant drug cost, from $4.16 PMPM in 2004 to $3.62 in 2005, compared with a 7.6% decrease (from $3.57 to $3.30 PMPM) in the comparison group. The 9.0% difference in drug cost per day represents drug cost savings of approximately $0.36 PMPM or $1,880,562 in 2005 dollars for this HMO of approximately 440,000 members. CONCLUSION: A step-therapy edit requiring HMO members to use a generic antidepressant, excluding tricyclics, prior to use of a brand-name antidepressant resulted in drug cost savings of 9.0% for the entire class of antidepressants, equal to $1,880,562 ($0.36 PMPM) in 2005 dollars in the first year of the intervention. A small (-1.5%) decrease in use of antidepressants occurred in the intervention group, which was less than the 5.0% decrease in utilization of antidepressants in the comparison group.

Antidepressive Agents↗