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IPS brought many changes for home health providers, including intensified claims review and audits, resulting in overpayments. Agencies have several options despite the limited protection they have under Medicare, including challenging determinations, rebutting the decision, requesting a waiver, and appealing decisions.
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Old Medicare claims in California, Florida, and New York are now subject to review by recovery audit contractors. To deal with these audits, providers should: Identify who within their organization will receive RAC communications. Review their practices in addressing government audits and claims of overpayment. Consider the compliance implications of the RAC's findings of overpayments.
Payers increasingly are subjecting claims to intensive review in an attempt to control amounts paid for healthcare services. An internal case management program, however, can help providers better understand and respond to the review techniques employed by payers as well as streamline overall claims processing.
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The recent growth in outpatient services has been the result of both increased use of new and improved technology, along with a shift to an ambulatory setting for many previously performed inpatient tests and procedures. Employers have seen an almost unchecked rapid growth in this portion of health care costs, with no signs of slowing down. This article attempts to show a basic step-by-step approach to identifying and reviewing some of the major cost generators through a managed care program.
Physicians might win back some lost autonomy if every ¿No¿ decision from an HMO medical director were subject to review by a state medical licensing board. But views differ on whether the boards should undertake such oversight responsibilities.
Because of a trend toward increased cost escalation outside of the hospital, in the ambulatory care setting, Metropolitan Life Insurance Company initiated an Ambulatory Utilization Review ("AUR") program in 1986. This is an overview of the lessons learned since that time. Some of what was learned was simply--or not so simply--"how to," the subject of this first article in a two-part series. Once this deceptively difficult technology was understood, there were two additional categories of lessons to learn: the extent of expected program results and some unexpected results. This second set of lessons is reviewed in Part II of the article.
STUDY OBJECTIVES: To estimate the efficacy of a medical record review for identifying adverse events and negligent case suffered by hospitalized patients. DESIGN: Cross-sectional study comparing an objective medical record review with information available from hospital quality assurance records as well as risk management and litigation records. SETTING: Two metropolitan teaching hospitals in the northeastern United States. MEASUREMENTS AND MAIN RESULTS: Using the litigation and risk management records as a criterion standard, we found that the medical record review had a sensitivity of 80% (93 of 116; 95% CI, 73% to 88%) for discovering adverse events and a sensitivity of 76% (51 of 67; 95% CI, 66% to 86%) for discovering negligent care. We estimated that record review of a random sample of hospitalizations across a geographic region would have even higher sensitivity (adverse-event sensitivity, 84%; negligence sensitivity, 80%). Moreover, we found that the adverse events we failed to discover led to less costly malpractice claims. A significant number of adverse events (20 of 172) among hospitalizations never gave rise to litigation or risk management investigation. Six of the twenty were due to negligent care. Quality assurance efforts at the level of the clinical departments in one hospital led to review of only 12 out of 82 risk management records. CONCLUSIONS: The overwhelming majority of adverse events and episodes of negligent care are discoverable with the methods we used to evaluate medical records. Quality assurance efforts using similar record review methods should be further evaluated.
BACKGROUND: The epidemiology, risks, and outcomes of errors in primary care are poorly understood. Malpractice claims brought for negligent adverse events offer a useful insight into errors in primary care. METHODS: Physician Insurers Association of America malpractice claims data (1985-2000) were analyzed for proportions of negligent claims by primary care specialty, setting, severity, health condition, and attributed cause. We also calculated risks of a claim for condition-specific negligent events relative to the prevalence of those conditions in primary care. RESULTS: Of 49345 primary care claims, 26126 (53%) were peer reviewed and 5921 (23%) were assessed as negligent; 68% of claims were for negligent events in outpatient settings. No single condition accounted for more than 5% of all negligent claims, but the underlying causes were more clustered with "diagnosis error" making up one third of claims. The ratios of condition-specific negligent event claims relative to the frequency of those conditions in primary care revealed a significantly disproportionate risk for a number of conditions (for example, appendicitis was 25 times more likely to generate a claim for negligence than breast cancer). CONCLUSIONS: Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations.
On the surface, there are many ways in which case mix may be considered, but the key to any successful system often lies below the surface, in the way in which the available data feed the systems, and in the operational environment in which the output is to be used. This article will review terminology used in case-mix adjustment and profiling techniques, highlight some dangerous (and avoidable) data pitfalls, and emphasize reasonable goals that can be achieved through the use of case-mix adjusted profiling.
Three recent studies provide, for the first time, the information needed to evaluate objectively the cost savings, utilization, worker satisfaction, and productivity differences of network versus nonnetwork care in workers' compensation cases. The authors review these studies and analyze their findings.
A state statute can require an HMO to provide for an independent medical review of a denial of a request for a particular treatment as not medically necessary and to provide the treatment if the reviewing physician determines the covered service is reasonably necessary. The statute is exempt from ERISA preemption as a law that regulates insurance.
OBJECTIVES: To characterize accepted workers' compensation claims for needlestick injuries filed by healthcare workers (HCWs) in non-hospital compared with hospital settings in Washington State. DESIGN: Descriptive study of all accepted workers' compensation claims filed between 1996 and 2000 for needlestick injuries. PARTICIPANTS: All Washington State HCWs eligible to file a state fund workers' compensation claim and those who filed a workers' compensation claim for a needlestick injury. RESULTS: There were 3,303 accepted state fund HCW needlestick injury claims. The incidence of needlestick injury claims per 10,000 full-time-equivalent HCWs in hospitals was 158.6; in dental offices, 104.7; in physicians' offices, 87.0; and in skilled nursing facilities, 80.8. The most common mechanisms of needlestick injury by work location were as follows: for hospitals, suturing and other surgical procedures (16.7%), administering an injection (12.7%), and drawing blood (10%); for dentists' offices, recapping (21.3%) and cleaning trays and instruments (18.2%); for physicians' offices, disposal (22.2%) and administering an injection (10.2%); and for skilled nursing facilities, disposal (23.7%) and administering an injection (14.9%). Nurses accounted for the largest (29%) proportion of HCWs involved, followed by dental assistants (17%) and laboratory technicians and phlebotomists (12%) in non-hospital settings. Rates of needlestick injury claims increased for non-hospital settings by 7.5% annually (95% confidence interval [CI95], 4.89% to 10.22%; P < .0001). Rates decreased for hospital settings by 5.8% annually, but the decline was not statistically significant (CI95, -12.50% to 1.34%; P < .1088). HCWs were exposed to hepatitis B, hepatitis C, and human immunodeficiency viruses in non-hospital settings. CONCLUSION: There was a difference in the incidence rate and mechanisms of needlestick injuries on review of workers' compensation claim records for HCWs in non-hospital and hospital settings.
A closed-claim analysis of anesthetic-related deaths and permanent injuries in the dental office setting was conducted in cooperation with a leading insurer of oral and maxillofacial surgeons and dental anesthesiologists. A total of 13 cases occurring between 1974 and 1989 was included. In each case, all available records, reports, depositions, and proceedings were reviewed. The following were determined for each case: preoperative physical status of the patient, anesthetic technique used (classified as either general anesthesia or conscious sedation), probable cause of the morbid event, avoidability of the occurrence, and contributing factors important to the outcome. The majority of patients were classified as American Society of Anesthesiologists (ASA) status II or III. Most patients had preexisting conditions, such as gross obesity, cardiac disease, epilepsy, and chronic obstructive pulmonary disease, that can significantly affect anesthesia care. Hypoxia arising from airway obstruction and/or respiratory depression was the most common cause of untoward events, and most of the adverse events were determined to be avoidable. The disproportionate number of patients in this sample who were at the extremes of age and with ASA classifications below I suggests that anesthesia risk may be significantly increased in patients who fall outside the healthy, young adult category typically treated in the oral surgical/dental outpatient setting.
In April 1989, the Health Care Financing Administration stopped publishing the parameters that trigger review of Medicare claims because they thought that knowledge of the parameters would permit providers to schedule visits to avoid review. In this article, the authors report the results of an experimental study where previously unrevealed parameters were revealed to some providers of Medicare services and not to others. The authors find little evidence to suggest that providers schedule procedures to avoid review when they know the parameters. There is some evidence, however, that providers may be responding to the release of the parameters in other ways.
A patient referred for physical therapy may attend one or several therapy visits or may continue to receive ongoing therapy services several times weekly for several months. The question of the continued medical necessity of those services arises often. Determination of medical necessity for continued therapy services requires knowledge of the natural history of diseases that may require therapy services, familiarity with the effectiveness of treatment alternatives for those diseases, and awareness of community practice patterns. Accurate and complete documentation from the therapist or referring physician is required for the physician advisor or utilization review consultant to make an accurate determination of medical necessity. A structured format for providing this documentation is suggested.
Appeals of denied precertifications have not received much attention from the managed care industry, in part because of ERISA's favorable liability climate. However, recent court cases, new accreditation standards, and increased incentives to physicians to economize on resource use may compound the risk inherent in commonly used appeals practices for both standard and investigational protocols. This article will review some common but high-risk appeals practices and suggest low-cost protocols that can virtually eliminate risk while increasing enrollee satisfaction.