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Under section 1869 of the Social Security Act, Medicare beneficiaries and, under certain circumstances, providers or suppliers of health care services may appeal adverse determinations regarding claims for benefits under Medicare Part A or Part B. This rule expands our regulations to recognize the right of Part B appellants to a hearing before an administrative law judge (ALJ) for claims if at least $500 remains in dispute and the right to judicial review of an adverse ALJ decision if at least $1,000 remains in controversy. Also, this rule codifies in regulations: Limitations on the review by ALJs and the courts of certain national coverage determinations, and the statutory authority for an expedited appeals process under Part A and Part B.
OBJECTIVES: To identify errors in surgical pathology practice that lead to malpractice claims, and to define the frequency and severity of pathology malpractice claims and discuss the implications. DESIGN: Three hundred seventy-eight pathology malpractice claims reported to The Doctors Company of Napa, Calif, between 1998 and 2003, were reviewed. Nuisance claims and autopsy claims were excluded; the 335 remaining claims were analyzed. RESULTS: Pathology claim frequency is low. Pathology claim severity is high, especially for claims involving a misdiagnosis of melanoma or a false-negative Papanicolaou test. Fifty-seven percent of claims involved the following 5 categories: breast specimens, melanoma, Papanicolaou smears, gynecologic specimens, and operational error. Sixty-three percent of claims involved failure to diagnose cancer, resulting in delay in diagnosis or inappropriate treatment. CONCLUSION: A false-negative diagnosis of melanoma is the single most common reason for filing a malpractice claim against a pathologist. Nearly one third of misdiagnoses involve melanoma misdiagnosed as Spitz nevus, "dysplastic" nevus, spindle cell squamous carcinoma, atypical fibroxanthoma, and dermatofibroma.
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Today's environment offers a host of utilization management challenges for healthcare providers. If hospitals are to minimize denials and reduce costs amid these pressures, they will need to adopt several key strategies, including effectively employing use of a dedicated physician adviser.
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A medical group must address practical and legal issues when it discovers improper payments, billing mistakes or alleged misconduct. Its response has a significant impact on how the charges are resolved. A group and its providers can come under fraud and abuse investigations, whistle-blower allegations and Medicare payment reviews. Many questions arise in response to billing errors or allegations of misconduct.
OBJECTIVE: To review and apply statistical tests to the selection criteria used by two medical advisers to approve or deny applications for three common cosmetic or reconstructive procedures within a large group of medical schemes. DESIGN: A retrospective descriptive study which applied multiple regression analysis, frequency analysis, comparison of means and simple correlations to the data sets for three procedures. SETTING: Administrative records from the clinical files of medical advisers and the administrator's claims database. SUBJECTS: Data were reviewed for 1,143 members who, between January and December 1996, submitted applications for breast reduction, excimer laser refractive surgery, or otoplasty. MAIN OUTCOME MEASURES: The primary outcome measure was the statistical relationship between medical advisers' selection criteria and final decision. In addition, the financial implications of these cosmetic/reconstructive procedures were assessed. RESULTS: For the three procedures reviewed there was a statistically significant relationship between 5 of 13 preoperative criteria requested and the medical advisers' opinion. Excimer laser surgery was generally approved on the basis of the refractive error (myopia > -3.00; astigmatism > -1.5 dioptres); otoplasty was generally approved for children aged > or = 12 years; and breast reduction was usually covered for women with a sternal-nipple distance > 29.0 cm and with a cup size > or = DD. The other data submitted were similarly distributed between the approved and denied groups. CONCLUSIONS: Review of medical advisers' decisions is important in an era of protocols, guidelines and 'standard operating procedures'. Selection criteria for approval of applications for medically necessary cosmetic/reconstructive surgery must be reviewed and revised to provide a reliable, reproducible and statistically valid process.
OBJECTIVE: This study evaluated the accuracy of 2 administrative claims-based selection rules to identify patients with hypertension (HTN) using medical records as the gold standard. RESEARCH DESIGN: The claims database consisted of inpatient, outpatient, pharmacy, and eligibility claims for members of a single insurance company from January 2000 through March 2003. Medical records were abstracted for 258 matched patient pairs selected by Rule A (at least 1 HTN-related International Classification of Diseases, 9th Revision [ICD-9] claim) and 138 pairs selected by Rule B (at least 1 HTN-related ICD-9 and at least 1 HTN prescription claim) from 31 provider sites. Sensitivity and specificity of the 2 selection rules were computed using medical chart review as the gold standard for a diagnosis of HTN. SUBJECTS: Of patients selected by Rule A, chart review identified 281 patients with and 235 patients without HTN. Of patients selected by Rule B, chart review identified 172 patients with and 104 patients without HTN. RESULTS: The sensitivity and specificity was 70.8% and 74.9% for Rule A and 76.2% and 93.3% for Rule B. The kappa score was 0.45 for Rule A and 0.65 for Rule B. CONCLUSION: To identify patients with HTN, a selection rule using both a diagnosis and prescription claim has greater sensitivity and specificity than a rule using a diagnosis claim only.
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.
This worksheet was developed in response to an ever increasing number and intensity of admission and concurrent telephone reviews conducted by third and fourth-party payors. This worksheet was developed as an aid in information gathering for subsequent telephone and other reviews. The left-margin headings evolved from queries for information from the most demanding psychiatric nurse reviewers. When I have fully addressed all the information in my review, it is usually no problem in obtaining certification for admission or continued stay for the patient.
With pressure building to reduce healthcare costs, relations between providers and insurers in the years ahead increasingly will focus on risk sharing and utilization controls. Fixed price agreements and managed care plans are two approaches expected to come into wider use. To cope with coming utilization reviews and efforts to manage outpatient care, hospitals will need information systems allowing them to evaluate patient mixes and service intensities.
This document concerns the Department of Veterans Affairs (VA) adjudication regulations. We are adding new provisions to allow any claimants who file a timely Notice of Disagreement to obtain a de novo review of their claims at the Veterans Service Center level before deciding whether to proceed with the traditional appeal process. This is intended to provide a more efficient means for resolving disagreements concerning claims.
Utilization management (UM) is now an integral part of most public and private health plans. Hospital review, until recently the primary focus of UM, is associated with a reduction in bed days and rate of hospital cost increases. These reductions appear to have had limited impact on aggregate health care costs because of increases in unmanaged services. In the future, with electronic connectivity between payers and providers and the use of clinical guidelines and computer-based decision-support systems, the need for prospective case-level reviews will be reduced. With these changes, UM programs are likely to become more acceptable to providers and patients.
The information in this issue brief is based on a 50--state survey and a recent literature review. The Health Policy Tracking Service recognizes the complexity of this issue and discourages the use of this document as a sole resource on the issue.
In this article, the 1987 conventional health plans are examined and 1987 group health insurance is compared with that of 1977. The source of information for 1987 is the national survey of 771 private and public employers conducted by the Health Insurance Association of America. Data for 1977 are from the National Medical Care Expenditures Survey. Findings show that conventional health plans' share of the group market declined from 95 to 73 percent during the decade; the majority of Americans covered by conventional group insurance are now enrolled in a plan that self-insures; prospective utilization review grew dramatically after 1984; and patient cost sharing increased, but not as significantly as conventional wisdom holds.
This article, the first of two, explains how health-care providers can increase their market share and profit margins and improve quality of care by marketing utilization review services. Selling these services to employers or other potential buyers requires reliable data and an understanding of the needs of various players in the marketplace.