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Results for “Insurance Claim Review”

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At least 973 records · Page 54Linked to original sources
PubMed2005

Risk of pneumonia and other complications of influenza-like illness in patients treated with oseltamivir.

BACKGROUND: Clinical trials suggest that the risk of pneumonia and other sequelae of influenza may be reduced in patients using oseltamivir. RESEARCH DESIGN AND METHODS: This retrospective cohort study used U.S. health insurance claims data. Patients were grouped into three cohorts: (1) diagnosed with influenza-like illness (ILI) and received a dispensing of oseltamivir; (2) diagnosed with ILI but received no antiviral medication; and (3) received oseltamivir without a physician diagnosis of ILI. Baseline factors assessed included demographics, history of drug dispensings, diagnoses, and vaccinations. MAIN OUTCOME MEASURES: Outcomes included diagnosis of pneumonia, dispensing of an antibiotic, or hospitalization within 30 days after an ILI diagnosis or oseltamivir dispensing. RESULTS: The adjusted hazard ratio for ILI with oseltamivir compared to ILI without antivirals for pneumonia was 0.72 (95% CI, 0.60-0.86), for antibiotic dispensing was 0.89 (95% CI, 0.86-0.93), and for hospitalization was 0.74 (95% CI, 0.61-0.90). The cohort who received oseltamivir without an ILI diagnosis did not differ significantly in risk of any outcome from the ILI with oseltamivir cohort. CONCLUSIONS: The risk of pneumonia, antibiotic dispensing, and hospitalization was reduced in patients with ILI who received oseltamivir compared to no antiviral therapy. These findings were based on health care claims only and have not been verified through medical record review.

Acetamides↗
PubMed1994

Using an appeals panel to mediate mental health care UR disputes.

The certification of admission and lengthy psychiatric hospitalizations raises fundamental issues related to the appropriateness of treatment. The author presents several case examples to illustrate how an appeals panel resolves disputed utilization review decisions regarding inpatient psychiatric treatment.

Decision Making, Organizational↗
PubMed1996

Variation in expert opinion in medical malpractice review.

BACKGROUND: Expert opinion in medical malpractice is a form of implicit assessment, based on unstated individual opinion. This contrasts with explicit assessment processes, which are characterized by criteria specified and stated before the assessment. Although sources of bias that might hinder the objectivity of expert witnesses have been identified, the effect of the implicit nature of expert review has not been firmly established. METHODS: Pairs of anesthesiologist-reviewers independently assessed the appropriateness of care in anesthesia malpractice claims. With potential sources of bias eliminated or held constant, the level of agreement was measured. RESULTS: Thirty anesthesiologists reviewed 103 claims. Reviewers agreed on 62% of claims and disagreed on 38%. They agreed that care was appropriate in 27% and less than appropriate in 32%. Chance-corrected levels of agreement were in the poor-good range (kappa = 0.37; 95% CI = 0.23 to 0.51). CONCLUSIONS: Divergent opinion stemming from the implicit nature of expert review may be common among objective medical experts reviewing malpractice claims.

Anesthesiology↗
PubMed1999

Carpal tunnel syndrome and workers' compensation among an occupational clinic population in New York State.

BACKGROUND: This study evaluated the experience in the New York State workers' compensation (WC) system of 135 patients with work-related carpal tunnel syndrome diagnosed at an academic occupational medicine clinic between 1991-1994. METHODS: Worker's Compensation Board (WCB) records were reviewed to ascertain: (1) the proportion of WC claims that were not initially accepted (i.e., that were challenged) by the WC insurer, (2) the proportion of challenged claims ultimately decided in the claimant's favor, (3) the length of the period between case filing and claim adjudication, and (4) risk factors for claim challenge. RESULTS: Seventy-nine percent of the claims were not initially accepted by the WC insurer (challenged/no response). Of the 81 challenged/no response cases adjudicated (ruled on) at the time of the study, 96.3% were accepted as work-related. Mean time from claim initiation to adjudication was 429 days (range 58-1,617). Mean time from physician request for any treatment and WCB authorization was 226 days (range 0-1,296). Mean time from physician request for surgery authorization and WCB authorization was 318 days (range 7-595). Claims filed by non-whites, low-wage workers, and union members were significantly more likely than others to be challenged. CONCLUSIONS: Patients with work-related carpal tunnel syndrome face frequent claim challenge by WC insurers in NY State, with attendant prolonged delays in adjudication and treatment authorization. Likelihood of claim rejection was strongly related to ethnicity and socio-economic status.

Carpal Tunnel Syndrome↗
PubMed1999

Revenge of the reviewed.

The managed care backlash has shifted to a new target: HMO medical directors. Federal law shields employer-sponsored health plans from most state oversight and lawsuits, but angry enrollees have begun taking a back route, turning state medical boards on doctors in charge of utilization review. One attorney calls them "the soft underbelly of managed care."

Insurance Claim Review↗
PubMed2006

Learning from litigation. The role of claims analysis in patient safety.

Claims for malpractice and medical negligence are a potentially important source of information on the causes of harm to patients and have provided valuable lessons in the past. However today, with many additional sources of information and methods of analysis, the role of claims analysis needs to be reappraised. We consider the role of claims analysis in relation to other methods of studying adverse outcomes, review previous studies of claims and summarize the findings of four recent British specialty claims reviews. Claims analysis has a number of inherent limitations. We suggest that there is now no case for ad hoc claims reviews which rely on data that have been assembled for legal purposes only. Claims review is still potentially useful for rare events or in cases where other sources of data are not available. However, future claims reviews need to meet basic criteria before being undertaken; these include prospective identification of the relevant questions and variables, adequacy and completeness of the data set, availability of expert reviewers and clear protocols for review.

Health Services Research↗
PubMed1993

Pre-billing DRG reviews set new standard.

When and how you do DRG review is critical. This piece offers tips on hiring consultants who can help you provide this financially important service.

Abstracting and Indexing↗
PubMed2006

Claiming behaviour in a no-fault system of medical injury: a descriptive analysis of claimants and non-claimants.

OBJECTIVES: (i) To determine the proportion of patients in New Zealand who claim compensation from the national no-fault compensation program after experiencing a compensable injury; and (ii) to identify characteristics of injured patients who are least likely to claim despite having sustained a compensable injury. DESIGN: We estimated the percentage of eligible patients who claim no-fault compensation by linking a national claims database (Accident Compensation Corporation) to records reviewed in the New Zealand Quality of Healthcare Study (NZQHS). Bivariate and multivariate analyses were used to investigate socioeconomic and sociodemographic differences between claimants and injured non-claimants. PARTICIPANTS AND SETTING: Patients who experienced an adverse event associated with care in NZ public hospitals in 1998 and claimed compensation with the ACC, the national no-fault insurer (n = 741). Patients identified by the NZQHS as having sustained an adverse event associated with hospital care in the same year who did not file a compensation claim (n = 839). MAIN OUTCOME MEASURES: Adverse events, compensable adverse events, and compensation claims. RESULTS: Among patients judged by NZQHS reviewers to be eligible for compensation, 2.9% (6/210) claimed. Odds of claiming after an adverse event were significantly lower for patients who were elderly (odds ratio [OR], 0.20; 95% CI, 0.14-0.28), from the most deprived areas (OR, 0.36; 95% CI, 0.23-0.57), or of Ma ori or Pacific ethnicity (OR, 0.47; 95% CI, 0.32-0.69 and OR, 0.26, 95% CI, 0.11-0.58). CONCLUSIONS: Despite few apparent institutional or economic barriers, the proportion of injured patients in NZ who seek compensation after sustaining a compensable injury is very low. Hence, substantial underclaiming occurs in both negligence and no-fault systems. The disproportionately low propensity of elderly, poor and minority patients to seek compensation also appears to be pervasive.

Adult↗
PubMedDate not supplied

A survey of human resources in managed care organizations.

Although managed health care is increasing exponentially in the United States, minimal published information exists regarding the human resources needed to perform various managed care activities. This article reports on the results of a national survey of managed care organizations regarding the quantitative use of nurse and physician reviewers and the type of activities being performed.

Insurance Claim Review↗