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PubMed2003

Insurers reign.

Double-digit premium increases, an easing of runaway cost growth and less competition have led to record profits and climbing stock prices for the nation's insurance companies. While the immediate outlook is rosy, there are hints that a backlash may be developing among providers and consumers disgruntled over the high premiums, and among policy-makers alarmed at the climb in the number of uninsured Americans, which is estimated at 41 million now and is expected by all forecasters to continue to surge.

Fees and Charges↗
PubMed2003

The New England Healthcare EDI Network.

The New England Healthcare EDI Network (NEHEN) is a collaborative of providers and payers in eastern Massachusetts that created, manages, and operates a shared insurance EDI infrastructure. NEHEN currently has 12 provider and three payer members, and supports over 1,000,000 insurance EDI transactions per month. This paper describes the philosophies that define the NEHEN business model and discusses its governance structure, technology, operational issues associated with its implementation, and its current status, along with lessons learned from the NEHEN undertaking.

Community Health Planning↗
PubMed2003

National Academy of Neuropsychology/Division 40 of the American Psychological Association Practice Survey of Clinical Neuropsychology in the United States. Part II: Reimbursement experiences, practice economics, billing practices, and incomes.

Leaders of the National Academy of Neuropsychology and Division 40 (Clinical Neuropsychology) of the American Psychological Association determined that current information on the professional practice of clinical neuropsychology within the United States was needed. These two organizations co-sponsored a national survey of U.S. clinical neuropsychologists that was conducted in September 2000. The primary goal of the survey was to gather information on such topics as: practitioner and practice characteristics, economic variables (e.g., experience with major third party payors, such as Medicare and managed care), practice expenses, billing methods, experiences with Current Procedural Terminology (CPT) codes, time spent on various clinical tasks, use of assistants, and income. In this second of two articles describing the survey results, reimbursement experiences, practice economics, billing practices, and incomes are highlighted. Survey results indicate that neuropsychologists frequently have difficulty gaining access to membership on managed care panels. For those who gain access, managed care companies often limit provision of services; this is quite often perceived as negatively affecting quality of patient care. It is very common for neuropsychologists to feel obligated to provide more services to managed care and Medicare patients than are allowed to be billed to the insurance carrier; these hours are typically "written off." Numerous CPT codes are used to bill the same clinical service. Awareness of Medicare practice and billing expectations is variable among practitioners, as is awareness of public aid/Medicaid billing status. Professional income is influenced by years of licensed practice, practice setting, gender, types and amounts of non-clinical professional activities, and types and amounts of reimbursement sources within one's clinical practice. Income of neuropsychologists has only a minimal relationship to percentage of clinical practice per week. Within the context of prior surveys, neuropsychologists are engaging in more clinical hours per week and, nevertheless, compared to data from 1993, are reporting decreased income. These and other findings are presented and discussed.

Academies and Institutes↗
PubMedDate not supplied

How your "free" tail liability policy is funded.

The Extended Reporting Endorsements for Claims-made Professional Liability policies are provided to insured doctors in the event of death, disability, and retirement (DDR) with no additional premium charge if certain criteria are met. However, this "free tail" policy is actually pre-funded via a percentage loading applied to all insureds' ongoing premium. The amount of this loading is determined by continual monitoring of the demographics of the insured population. This article sheds light on the process used by professional liability companies to price "free tail" policies and reviews the key concepts involved.

Humans↗
PubMed2003

Prevalence of inflammatory bowel disease in an insured population in Puerto Rico during 1996.

OBJECTIVES: Limited data exists about Inflammatory Bowel Disease (IBD) in Hispanic populations. The aims of the present study were to estimate overall and specific prevalence of IBD (Crohn's disease and ulcerative colitis) and to describe the characteristics of a group of patients from the University of Puerto Rico's IBD Registry. METHODS: To estimate the prevalence of IBD, computerized records of all physician billing and hospital discharges from a major health insurer in Puerto Rico and classified with ICD-9-CM codes 555.0-555.9 (Crohn's disease) and 556.0-556.9 (ulcerative colitis) during 1996 were searched. Prevalence was estimated by age group, sex, and type of insurance. To describe demographic and selected clinical information from patients with IBD, data gathered in the University of Puerto Rico's IBD Registry from 1995 through 2000 was analyzed. RESULTS: Out of 802,726 insured individuals, 332 had a diagnosis of Crohn's disease, 499 of ulcerative colitis and 21 had both diagnoses. The estimated prevalence per 100,000 was 41.4 for Crohn's disease, 62.2 for ulcerative colitis, and 106.1 cases per 100,000 for IBD. Peak prevalence of Crohn's disease occurred among the age groups 50-59 years and > or = 60 years, and the overall female:male prevalence ratio of Crohn's disease was 1.13 (95% CI: 0.91-1.42). Ulcerative colitis was most prevalent among insured individuals aged 50-59 years and 40-49 years. The prevalence of ulcerative colitis was significantly higher among females than among males, with an overall prevalence ratio of 1.42 (95% CI: 1.18-1.71). Of 342 patients participating in the IBD Registry, 155 (45.3%) had Crohn's disease and 187 (54.7%) had ulcerative colitis. Among patients diagnosed with Crohn's disease, 51.6% were females, the mean age was 35.2 +/- 18.3 years, and 18.1% had a family history of IBD. More than half (57.8%) of patients with ulcerative colitis were females, the mean age was 42.6 +/- 17 years, and 17.1% had a family history of IBD. CONCLUSIONS: The estimated prevalence of IBD in this insured population in Puerto Rico places it among the middle-range of that reported for other countries. Additional studies must be conducted in Puerto Rico in order to confirm the observed findings. Population-based epidemiologic studies aimed at estimating the burden of IBD in Hispanic populations in the United States and Latin America are essential for health care planning.

Adolescent↗
PubMedDate not supplied

Insurance 101.

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Hawaii↗
PubMedDate not supplied

An EPLI primer.

Explore the source record for details and available documents.

Hawaii↗
PubMed2003

[New therapeutic options in obesity].

The basis for a therapeutic concept for obesity comprises specific measures aimed at changing inappropriate lifestyle habits (overeating, unsuitable diet, sedentary lifestyle) and psychological counseling (identification of bad eating habits, motivation, intensive coaching). Education by a physician on an individual or small-group basis, with emphasis on the practical implementation of fitness training (endurance and muscle building!), together with modification of the diet, has proved successful. In parallel with this, supportive anti-obesity medication makes a useful contribution to weight reduction and the control of risk factors. Evidence-based anti-obesity drugs such as sibutramine and orlistat facilitate the start of weight reduction, thus providing additional motivation of success, and support the long-term effect by stabilizing the weight loss. Health insurance carriers should, in future, selectively support evaluated and approved medication-based and non-medication-based weight-reduction programs, and reimburse the patient who has successfully participated in one.

Adult↗
PubMed2003

[New stipulations for rehabilitation of mentally ill. Will return to normal life be facilitated?].

Current changes in the laws pertaining to mental disorders are mainly concerned with the redefinition in the Sozialgesetzbuch IX (SGB IX) [Social Law] of the term "disability", and the forthcoming introduction of the International Classification of Functioning, Disability and Health (ICF). Accordingly, the rehabilitation of the mentally disturbed will be based on an integrative bio-psychosocial treatment concept, which--in parallel with curative therapy--right from the beginning envisages measures aimed at reintegration of the patient into daily/occupational life. On the basis of the ICF, all patients with mental disorders of more than 6 months' duration may be classified by the medical services of the health insurance carriers as being in need of rehabilitation. Appropriate care-related structures in psychiatric and psychosomatic areas are to some extent already available.

Activities of Daily Living↗