Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “Insurance Claim Review”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 1,351 records · Page 75Linked to original sources
PubMedDate not supplied

Prescription analgesic and antidepressant utilization and cost among elderly Medicaid beneficiaries before and after nursing home admission.

OBJECTIVES: The objectives of this study were to describe changes in prescription analgesic and antidepressant medications and to track the costs associated with these medication changes when elderly Medicaid beneficiaries move from the community to a nursing home setting. DESIGN: Retrospective analysis of Medicaid long-term care and drugs claims data for fiscal year 2000 from three different states. SETTING: Long-term care facilities in three different states. PARTICIPANTS: We studied 1321 elderly Medicaid beneficiaries newly admitted to a nursing home during the study period. MEASUREMENTS: Pain medications were grouped into four different categories and all antidepressants were grouped into one category. For each medication category, we obtained the number of unique patients for whom it was prescribed, the number of days it was prescribed, and the amount paid by Medicaid. We then calculated the percentage of subjects prescribed and the amount paid per day for each medication class before and after nursing home admission. RESULTS: Except for skeletal muscle relaxants, 21% to 39% of beneficiaries already had claims linked to each medication class while still living in the community. After nursing home admission, the percentage of beneficiaries exposed to each medication class increased by 2% to 33%. Cost per day of therapy increased by 10% to 83%. There was significant variation among the states in utilization and cost per day of therapy. CONCLUSIONS: We draw three major conclusions: (1) community-dwelling elderly Medicaid beneficiaries in this study use more prescription analgesics and antidepressants than community-dwelling elders in prior studies; (2) there is a significant increase in medication utilization and cost on nursing home admission; and (3) significant variability in medication use and cost exists among the three states examined. Further investigation to elucidate the reasons for these differences could assist legislators in formulating sound public policy to contain Medicaid expenditures without sacrificing patient care.

Aged↗
PubMed2004

Association between SSRI use and hip fractures and the effect of residual confounding bias in claims database studies.

BACKGROUND: Although use of selective serotonin reuptake inhibitor (SSRI) antidepressants has been associated with hip fractures in claims data studies, it has been suggested that such results may be confounded by cognitive and functional status for which no information is available in claims data. Using survey data, we determined the magnitude of such bias and corrected the association between SSRI use and hip fractures accordingly. METHODS: We used the Medicare Current Beneficiary Survey to determine the association between SSRI use and 5 potential confounding factors not measured in Medicare claims data: body mass index, smoking, activities of daily living score, cognitive impairment, and Rosow-Breslau physical impairment scale. For 7126 participants aged > or =65 years, we estimated the association between SSRI use and these potential confounders. Combined with literature estimates of the associations between confounders and hip fractures, we were able to compute the extent of residual confounding bias caused by a failure to adjust for these factors. RESULTS: Comparing SSRI users with nonusers, there was considerable overestimation of an association with hip fractures if activities of daily living scores (+21.5% bias) or Rosow-Breslau impairment scales (+10.6%) are unmeasured in claims data. All 5 unmeasured confounders together resulted in net confounding of +9.6% (range: -0.3% to + 39%). After correction for this bias, the strength of association observed in claims data after bias correction (RR = 1.8; 95% CI = 1.5 to 2.1) was comparable to a recent clinical study (RR = 1.5; 0.6 to 3.8), but the claims data study achieved formal statistical significance due to its much large size (8239 vs. 288 hip fractures). CONCLUSIONS: Epidemiologic claims data studies tend to overestimate the relation between antidepressant use and hip fractures. However, after correcting for such bias, a significant association persists.

Aged↗
PubMed2003

Employer satisfaction with workers' compensation health care: results of the Washington State Workers' Compensation Managed Care Pilot.

Developing more effective approaches to disability prevention has been a longstanding challenge for the workers' compensation system. A major obstacle to this goal has been the lack of communication and interaction between employers and physicians who care for injured workers. From 1995 through 1997, the Washington State Department of Labor and Industries sponsored a major demonstration program, known as the managed care pilot (MCP), to assess the effects of managed care on medical and disability costs, patient satisfaction and employer satisfaction. We developed a telephone survey and administered it to 243 employers as part of the MCP evaluation. Topics covered in this survey include satisfaction with treatment rendered, duration of lost work time, work modifications, and satisfaction with communication received during the employee's recovery period. Employers in the intervention (managed care) condition were more satisfied with the managed care/occupational medicine system than the employers in the comparison group were with the fee-for-service system. MCP employers were satisfied particularly with the frequency and quality of communication received from the health care provider regarding return to work and work modification issues. Improved employer-provider communication may foster early return to work and thereby have a beneficial effect on health and employment outcomes for injured workers.

Fee-for-Service Plans↗
PubMed2003

Ten years' experience using an integrated workers' compensation management system to control workers' compensation costs.

This work presents 10 years of experience using an Integrated Workers' Compensation Claims Management System that allows safety professionals, adjusters, and selected medical and nursing providers to collaborate in a process of preventing accidents and expeditiously assessing, treating, and returning individuals to productive work. The hallmarks of the program involve patient advocacy and customer service, steerage of injured employees to a small network of physicians, close follow-up, and the continuous dialogue between parties regarding claims management. The integrated claims management system was instituted in fiscal year 1992 servicing a population of approximately 21,000 individuals. The system was periodically refined and by the 2002 fiscal year, 39,000 individuals were managed under this paradigm. The frequency of lost-time and medical claims rate decreased 73% (from 22 per 1000 employees to 6) and 61% (from 155 per 1000 employees to 61), respectively, between fiscal year 1992 and fiscal year 2002. The number of temporary/total days paid per 100 insureds decreased from 163 in fiscal year 1992 to 37 in fiscal year 2002, or 77%. Total workers' compensation expenses including all medical, indemnity and administrative, decreased from $0.81 per $100 of payroll in fiscal year 1992 to $0.37 per $100 of payroll in fiscal year 2002, a 54% decrease. More specifically, medical costs per $100 of payroll decreased 44% (from $0.27 to $0.15), temporary/total, 61% (from $0.18 to $0.07), permanent/partial, 63% (from $0.19 to $0.07) and administrative costs, 48% ($0.16 to $0.09). These data suggests that workers' compensation costs can be reduced over a multi-year period by using a small network of clinically skilled health care providers who address an individual workers' psychological, as well as physical needs and where communication between all parties (e.g., medical care providers, supervisors, and injured employees) is constantly maintained. Furthermore, these results can be obtained in an environment in which the employer pays the full cost of medical care and the claimant has free choice of medical provider at all times.

Accidents, Occupational↗
PubMed2006

The cost of lifestyle health risks: obesity.

OBJECTIVE: The objective of this study was to provide employers interested in lifestyle health initiatives a resource for estimating their members' obesity-related costs stratified by demographics and business sector. METHOD: Claims-level medical costs attributable to obesity are estimated. Data come from 61 U.S. employers' health plan members' claims experienced between January 2000 and December 2004. RESULTS: Diagnosed, nondrug medical expenses attributable to obesity account for 21.3% of lifestyle and 2.8% of all medical costs for those aged 19 to 64 years. Obesity costs for children under 19 years are negligible. Up to age 64 years, females' obesity costs markedly exceed males'. At particular risk for high obesity costs are women, those aged 55 to 64 years, and healthcare sector members. CONCLUSIONS: Obesity is a costly lifestyle health risk and self-insured employers should take action with or without policy aid such as the HeLP Act S2558.

Adult↗
PubMed2006

Clinical and social predictors of application for social security disability insurance by workers' compensation claimants with low back pain.

OBJECTIVE: The objective of this study was to identify clinical and social predictors of application for Social Security Disability Insurance (SSDI) in workers' compensation claimants with low back pain. METHODS: Archival and interview data were analyzed for 1372 Missouri claimants who were, on average, nearly 42 months postinjury. RESULTS: Two hundred sixty-five (19.3%) claimants were receiving SSDI (8.0%) or had applied for SSDI (11.3%). Logistic regression indicated that black race, older age, herniated disc diagnosis, surgery, and longer time since injury were associated with increased odds of SSDI. Higher preinjury wage, more education, and higher satisfaction with medical treatment and/or treatment by employer were associated with decreased odds of SSDI. CONCLUSIONS: Application for SSDI among claimants with occupational low back pain is associated with social factors like race, satisfaction, and socioeconomics as well as clinical factors like diagnosis and surgery.

Adolescent↗
PubMed2005

Predictive modeling of total healthcare costs using pharmacy claims data: a comparison of alternative econometric cost modeling techniques.

OBJECTIVE: We sought to evaluate several statistical modeling approaches in predicting prospective total annual health costs (medical plus pharmacy) of health plan participants using Pharmacy Health Dimensions (PHD), a pharmacy claims-based risk index. METHODS: We undertook a 2-year (baseline year/follow-up year) longitudinal analysis of integrated medical and pharmacy claims. Included were plan participants younger than 65 years of age with continuous medical and pharmacy coverage (n = 344,832). PHD drug categories, age, gender, and pharmacy costs were derived across the baseline year. Annual total health costs were calculated for each plan participant in follow-up year. Models examined included ordinary least squares (OLS) regression, log-transformed OLS regression with smearing estimator, and 3 two-part models using OLS regression, log-OLS regression with smearing estimator, and generalized linear modeling (GLM), respectively. A 10% random sample was withheld for model validation, which was assessed via adjusted r, mean absolute prediction error, specificity, and positive predictive value. RESULTS: Most PHD drug categories were significant independent predictors of total costs. Among models tested, the OLS model had the lowest mean absolute prediction error and highest adjusted r. The log-OLS and 2-part log-OLS models did not predict costs accurately as the result of issues of log-scale heteroscedasticity. The 2-part model using GLM had lower adjusted r but similar performance in other assessment measures compared with the OLS or 2-part OLS models. CONCLUSION: The PHD system derived solely from pharmacy claims data can be used to predict future total health costs. Using PHD with a simple OLS model may provide similar predictive accuracy in comparison to more advanced econometric models.

Adolescent↗
PubMed2006

Data sources for measuring comorbidity: a comparison of hospital records and medicare claims for cancer patients.

BACKGROUND: Identifying appropriate comorbidity data sources is a key consideration in health services and outcomes research. OBJECTIVE: Using cancer patients as an example, we compared comorbid conditions identified: 1) on the discharge facesheet versus full hospital medical record and 2) in the hospital record versus Medicare claims, both precancer diagnosis and associated with a cancer treatment-related index hospitalization. METHODS: We used data from 1995 Surveillance, Epidemiology and End Results patterns of care studies for 1,382 patients. Comorbid conditions were ascertained from the hospital record associated with the most definitive cancer treatment and Medicare claims. We calculated the prevalence for and assessed concordances among 12 conditions derived from the hospital record facesheet; full hospital record; Medicare claims precancer diagnosis, with and without a rule-out algorithm applied; and Medicare claims associated with an index hospitalization. RESULTS: The proportion of patients with one or more comorbid conditions varied by data source, from 21% for the facesheet to 85% for prediagnosis Medicare claims without the rule-out algorithm. Condition prevalences were substantially lower for the facesheet compared with the full hospital record. For prediagnosis Medicare claims, condition prevalences were more than 1.7 times greater in the absence of an algorithm to screen for rule-out diagnoses. Measures assessing concordance between the full hospital record and prediagnosis Medicare claims (rule-out algorithm applied) showed modest agreement. CONCLUSIONS: The hospital record and Medicare claims are complementary data sources for identifying comorbid conditions. Comorbidity is greatly underascertained when derived only from the facesheet of the hospital record. Investigators using Part B Medicare claims to measure comorbidity should remove conditions that are listed for purposes of generating bills but are not true comorbidities.

Aged↗
PubMed2003

Do clinicians screen Medicaid patients for syphilis or HIV when they diagnose other sexually transmitted diseases?

BACKGROUND: Patients diagnosed with gonorrhea or chlamydia are at high risk for HIV and syphilis, and should be offered screening for both. GOAL: This study measures HIV and syphilis screening rates among Medicaid patients diagnosed with another sexually transmitted disease (STD). STUDY DESIGN: Using 1998 Medicaid claims data from 4 states, we identified individuals diagnosed with gonorrhea, urogenital chlamydia, or pelvic inflammatory disease, and then measured the proportion receiving screening tests for HIV and syphilis. RESULTS: Only 25% of STD-diagnosed Medicaid patients received screening tests for syphilis and only 15% for HIV. We found significant state-to-state variability in screening rates. CONCLUSION: Medicaid patients diagnosed with a nonbloodborne STD represent a high-risk group that is not adequately screened for syphilis and HIV despite repeated contact with medical professionals. Interventions should focus on eliminating missed opportunities for screening these high-risk individuals.

Adolescent↗
PubMed2007

Patterns in prenatal syphilis screening among Florida Medicaid enrollees.

OBJECTIVE: The objective of this study was to assess the rate of prenatal syphilis screening and compliance with clinical guidelines on the receipt of early and repeat screening in a Medicaid population before and after implementation of the National Plan to Eliminate Syphilis. STUDY DESIGN: Rates of office- and clinic-based prenatal syphilis screening among pregnant women with Medicaid-covered deliveries in Florida in fiscal years (FYs) 1995 and 2000 are analyzed using Medicaid claims data. RESULTS: The proportions of women receiving any, early, and repeat prenatal syphilis screening increased sharply between FY 1995 and FY 2000 but remain well below recommended levels. Screening is highly correlated with timing of prenatal care and Medicaid enrollment duration. CONCLUSIONS: Further efforts to improve screening rates will need to both increase the proportion of women who receive timely prenatal care and ensure that providers comply with guidelines to provide syphilis screening as a component of prenatal care for all women.

Adolescent↗
PubMed2004

Relationship between malpractice claims and medical care quality.

The purpose of this paper was to examine the relationship between medical malpractice claims and medical care quality in Taiwan. The Delphi technique with an expert panel was used to determine the relationship between malpractice and medical quality. A total of 371 medical malpractice claims were analyzed. Main measures included the rate and strength of malpractice cases associated with quality and the identification of the quality factors influencing the occurrence of malpractice. Results showed that malpractice claims were associated with internal medicine cases, surgery cases, pediatric cases, obstetricc and gynecological cases, physicians' professional competence, nonacceptable outcomes, complications, and poor communication. Concludes that medical malpractice cases could be avoided by increasing physicians' professional knowledge, practical skills, and communication.

Clinical Competence↗
PubMed2003

Using claims data to examine mortality trends following hospitalization for heart attack in Medicare.

OBJECTIVE: To see if changes in the demographics and illness burden of Medicare patients hospitalized for acute myocardial infarction (AMI) from 1995 through 1999 can explain an observed rise (from 32 percent to 34 percent) in one-year mortality over that period. DATA SOURCES: Utilization data from the Centers for Medicare and Medicaid Services (CMS) fee-for-service claims (MedPAR, Outpatient, and Carrier Standard Analytic Files); patient demographics and date of death from CMS Denominator and Vital Status files. For over 1.5 million AMI discharges in 1995-1999 we retain diagnoses from one year prior, and during, the case-defining admission. STUDY DESIGN: We fit logistic regression models to predict one-year mortality for the 1995 cases and apply them to 1996-1999 files. The CORE model uses age, sex, and original reason for Medicare entitlement to predict mortality. Three other models use the CORE variables plus morbidity indicators from well-known morbidity classification methods (Charlson, DCG, and AHRQ's CCS). Regressions were used as is--without pruning to eliminate clinical or statistical anomalies. Each model references the same diagnoses--those recorded during the pre- and index admission periods. We compare each model's ability to predict mortality and use each to calculate risk-adjusted mortality in 1996-1999. PRINCIPAL FINDINGS: The comprehensive morbidity classifications (DCG and CCS) led to more accurate predictions than the Charlson, which dominated the CORE model (validated C-statistics: 0.81, 0.82, 0.74, and 0.66, respectively). Using the CORE model for risk adjustment reduced, but did not eliminate, the mortality increase. In contrast, adjustment using any of the morbidity models produced essentially flat graphs. CONCLUSIONS: Prediction models based on claims-derived demographics and morbidity profiles can be extremely accurate. While one-year post-AMI mortality in Medicare may not be worsening, outcomes appear not to have continued to improve as they had in the prior decade. Rich morbidity information is available in claims data, especially when longitudinally tracked across multiple settings of care, and is important in setting performance targets and evaluating trends.

Adolescent↗
PubMed2004

Do written consent forms provide medicolegal protection from litigation in radiotherapy?

Two methods were used in an attempt to determine whether written consent forms serve a useful medicolegal purpose in Australian radiotherapy departments. First a survey was posted to all practising radiation oncologists to ask about their use of written consent forms and whether they had ever been useful in any claims made against them. Second, the largest medical defence organization in Australia was contacted for de-identified details about every claim ever made against a radiation oncologist. The survey yielded a response rate of 50.3%. Only one respondent indicated that any consent form had ever played a role in any claim and was not prepared to discuss it. Many radiation oncologists did not routinely use a consent form and its use could not be considered standard practice. The submitted consent forms generally did not contain warnings to the patient about specific risks of treatment. The details of the previous claims provided by the medical defence organization indicated that more often claims arose from circumstances in which a written consent form could not provide any useful protection such as radiation dose calculation errors. The medicolegal value of written consent forms in radiotherapy seems low, although further research may be necessary before dispensing with them completely.

Australia↗
PubMed2002

Use of interstate services for the termination of pregnancy in Australia.

OBJECTIVE: To document the extent to which women in Australia access interstate termination of pregnancy services and to determine whether the pattern of these claims suggests that the legal and political climate in particular jurisdictions is related to the use of services interstate. METHODS: The differences between the number of claims for Medicare Benefits Schedule item 35643 by place of patient residence and by place of service provision were analysed for 1984/85 to 1999/2000 inclusive. For States and Territories in which the differences were sufficiently large to be interpretable against the differences of contiguous States or Territories, the symmetry and correlation were assessed. RESULTS: Each year there were more claims by residents than there were claims for services provided in Tasmania (averaging 294 claims/year), Queensland (2,141) and the ACT (1,132). Conversely, each year there were fewer claims for services provided in Victoria (401) and in NSW/ACT combined (2,236). Strong correlations were found between time trends of the difference between claims by State of service and claims by State of residence for NSW/ACT and Queensland (0.983, p < 0.0001) and between trends for Tasmania and Victoria (0.774, p < 0.0005). After assuming that NSW provided all the estimated claims made by Queensland residents for interstate services, the correlation between the ACT and NSW was found to be very strong (0.931, p < 0.0001). CONCLUSIONS: Residents of some jurisdictions appeared to be accessing services interstate. IMPLICATIONS: States and Territories that do not provide appropriate services for their residents burden patients with additional costs and reduced support. Ensuring equitable access to termination of pregnancy services remains a public health issue that must be understood and addressed on a national level.

Abortion, Induced↗
PubMed2006

The effect of substance abuse treatment on Medicaid expenditures among general assistance welfare clients in Washington state.

Little is currently known about the effect of substance abuse treatment on Medicaid expenses and other health care costs for welfare clients. This study examined the association between substance abuse treatment and reductions in medical care expenditures (primarily Medicaid expenses) for General Assistance (GA) welfare clients in Washington State. The treatment group included 3,235 GA clients who received treatment during 2000 or 2001. The comparison group included 4,863 GA clients who needed substance abuse treatment but did not receive it. Substance abuse treatment was associated with a reduction (p < .01) in medical expenses of approximately 2,500 US dollars annually. This estimated savings equaled the cost of treatment and represented approximately 35 percent of the annual Medicaid expenses incurred by GA clients with substance abuse problems.

Adult↗
PubMed2004

An algorithm for the use of Medicare claims data to identify women with incident breast cancer.

OBJECTIVE: To develop and validate a clinically informed algorithm that uses solely Medicare claims to identify, with a high positive predictive value, incident breast cancer cases. DATA SOURCE: Population-based Surveillance, Epidemiology, and End Results (SEER) Tumor Registry data linked to Medicare claims, and Medicare claims from a 5 percent random sample of beneficiaries in SEER areas. STUDY DESIGN: An algorithm was developed using claims from 1995 breast cancer patients from the SEER-Medicare database, as well as 1995 claims from Medicare control subjects. The algorithm was validated on claims from breast cancer subjects and controls from 1994. The algorithm development process used both clinical insight and logistic regression methods. DATA EXTRACTION: Training set: Claims from 7,700 SEER-Medicare breast cancer subjects diagnosed in 1995, and 124,884 controls. Validation set: Claims from 7,607 SEER-Medicare breast cancer subjects diagnosed in 1994, and 120,317 controls. PRINCIPAL FINDINGS: A four-step prediction algorithm was developed and validated. It has a positive predictive value of 89 to 93 percent, and a sensitivity of 80 percent for identifying incident breast cancer. The sensitivity is 82-87 percent for stage I or II, and lower for other stages. The sensitivity is 82-83 percent for women who underwent either breast-conserving surgery or mastectomy, and is similar across geographic sites. A cohort identified with this algorithm will have 89-93 percent incident breast cancer cases, 1.5-6 percent cancer-free cases, and 4-5 percent prevalent breast cancer cases. CONCLUSIONS: This algorithm has better performance characteristics than previously proposed algorithms. The ability to examine national patterns of breast cancer care using Medicare claims data would open new avenues for the assessment of quality of care.

Aged↗