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PubMed1999

Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals.

BACKGROUND AND STUDY AIMS: Increasing numbers of patients are undergoing endoscopic retrograde cholangiopancreatography (ERCP) prior to laparoscopic cholecystectomy, and more departments and doctors are performing ERCP, while new data from large prospective series have documented the risks of both diagnostic and therapeutic ERCP. The establishment in Denmark of a Patient Insurance Association, which has covered injury caused during investigation and treatment in public hospitals since July 1992, has made it possible to collect and analyze a large prospective series of ERCP complications for which compensation has been claimed. PATIENTS AND METHODS: Thirty-nine consecutive claims for compensation due to complications after ERCP occurring between 1 July 1992 and 31 December 1996 were investigated. Case notes were reviewed, along with laboratory reports and radiographs. The complications were classified according to the international consensus. RESULTS: Claims for compensation were made in 39 cases from 25 hospitals. The indication for ERCP was appropriate in 31. Precut papillotomy for access had been performed in seven. The severity of the complications was mild in one patient, moderate in three patients, severe in 24, and fatal in nine; in two cases, the severity was not classifiable. The complications were: pancreatitis in 23 patients (seven cases fatal, one of which had involved a precut procedure), bleeding in two, perforation in nine (six had a precut procedure, one died), and other reasons in five (including one fatal case). Among the nine fatal cases, cannulation had not been achieved in two and the endoscopic retrograde cholangiogram was normal in four, one of whom underwent a sphincterotomy. One patient with a previous adenoma had an endoprosthesis removed, developed gangrenous cholecystitis afterward, and died. Thirty patients were eligible for compensation. The rejected cases included mild and moderate pancreatitis, a case of fatal hemorrhagic pancreatitis in which the patient had refused blood transfusion, and one patient who had pancreatitis prior to ERCP. CONCLUSIONS: ERCP, even for diagnostic purposes, may be associated with very serious and even fatal complications. The use of the precut procedure for access should still be considered dangerous. Other means of investigating the bile ducts should be developed. If endoscopic ultrasonography and magnetic resonance cholangiography prove to have the same diagnostic value as ERCP, which must be considered the gold standard for visualizing the ducts today, they might replace ERCP as the primary investigation in patients with an intermediate or low risk of bile duct stones; this would reduce the numbers of patients exposed to the risks of ERCP.

Adult↗
PubMedDate not supplied

How to complete a medical insurance form.

The information submitted is knowledge accumulated over years of experience teaching dentists how to bill medical insurance. This is supplemented with a good number of personal expert witness testimonies in criminal and malpractice insurance cases. The objective is to prevent problems before they start with the prudent use of information. My experience in court testimony on these issues has shown me that there is an army of lawyers, insurance company fraud examiners, and dentists working for the aforementioned, just waiting for you to improperly use this method of insurance reimbursement. Use this only if you understand the nuances of what it is you are doing! For example, any procedure you bill to dental insurance using CDT-2 codes can be billed to medical insurance using medical insurance CPT-95 codes. The difference is that if the procedure is not a covered medical expense, it will not be paid by the medical insurance carrier. I strongly suggest that you do not fall into the trap of obfuscating these codes. There are a number of so-called insurance "gurus" teaching dentists how to write confusing and misleading operative reports so as to obtain reimbursement for procedures that normally would not be covered. I beseech you--please do not do it! The penalties are severe. You will experience a significant increase in payments from the medical insurance when procedures are submitted in the proper manner. More and more computerized dental insurance management programs are offering their clients the ability to automatically cross-code and submit dental/medical insurance claims. It is a recognized ability of dentists to do such. Billing responsibly is of the utmost importance.

Forms and Records Control↗
PubMed1999

Risk pools: payers and providers take the plunge.

Providers considering managed care risk pool arrangements should understand thoroughly what services the pool covers, the time period covered, and how the pool is administered. Important issues related to pool administration include how credits and debits are applied; when the accounting occurs (interim, year-end, or contract termination); and provisions for reports, audit rights, and dispute resolution. Although a pool arrangement gives the health plan control over claims payment, the risk allocation made possible through a pool arrangement helps ensure that the economic incentives of the health plan and the provider are aligned.

Capitation Fee↗
PubMed2002

Prompt payment depends on revenue-cycle diligence.

How effectively you manage the revenue cycle is reflected in the cycle's outcome-whether you receive full and timely payment for all services billed to payers. To ensure prompt and full payment, you should: Educate your patient financial services (PFS) staff on all relevant laws and regulations regarding payment for healthcare services. Make sure your staff is well versed in all of the provisions of your payer contracts. Implement a state-of-the-art patient accounting system that is capable of producing drill-down reports of all aspects of contract performance by payer. Enforce payer compliance by maintaining complete records of dates of service, final billing dates, dates claims were mailed or electronically submitted to the payer, all actions performed by your staff regarding claims, and all communications with the payer.

Accounting↗
PubMed1991

Payment of hospital cardiac services.

This report describes how acute-care community hospitals in the United States get paid for services when their patients either are entitled to Medicare or Medicaid benefits or subscribe to a Blue Cross or Blue Shield plan, a commercial insurance plan, a health maintenance organization, a preferred provider organization, or some other third-party payment mechanism. The focus of this report is on cardiac services, which are the most common type of inpatient services provided by acute-care community hospitals. Over the past three decades, extraordinary advances in medical and surgical technologies as well as healthier life-styles have cut the annual death rate for coronary heart disease in half. Despite this progress, cardiovascular disease remains the number one cause of hospitalization. On average nationwide, diseases and disorders of the circulatory system are the primary reason for 17 percent of all patient admissions, and among the nation's 35 million Medicare beneficiaries they are the primary reason for 25 percent of all admissions. In the United States heart disease is the leading cause of death and a major cause of morbidity. Its diagnosis and treatment are often complex and costly, often requiring multiple hospitalizations and years of medical management. To focus management attention and resources on the immense cardiology marketplace, many hospitals have hired individuals with strong clinical backgrounds to manage their cardiology programs. These "front-line" managers play a key role in coordinating a hospital's services for patients with cardiovascular disease. Increasingly, these managers are being asked to become active participants in the reimbursement process. This report was designed to meet their needs. Because this report describes common reimbursement principles and practices applicable to all areas of hospital management and because it provides a "tool kit" of analytical, planning, and forecasting techniques, it could also be useful to hospital marketing, planning, finance, and accounting personnel. In addition, the rich reservoir of data contained in the appendixes to this report may be of interest to hospital chief executive officers, cardiologists, and cardiovascular surgeons. In addition to the introduction and summary sections, this report contains five main sections. Sequentially, these deal with: the ways hospitals get paid for what they do; ICD-9 coding DRGs, PPS, and Medicare claims administration; ways to analyze how well your hospital is doing; planning and forecasting; the new Resource-Based Relative Value Scale.(ABSTRACT TRUNCATED AT 400 WORDS)

Abstracting and Indexing↗
PubMed2004

Enhanced identification of postoperative infections among outpatients.

We investigated using administrative claims data to identify surgical site infections (SSI) after breast surgery and cesarean section. Postoperative diagnosis codes, procedure codes, and pharmacy information were automatically scanned and used to identify claims suggestive of SSI ("indicators") among 426 (22%) of 1,943 breast procedures and 474 (10%) of 4,859 cesarean sections. For 104 breast procedures with indicators explained in available medical records, SSI were confirmed for 37%, and some infection criteria were present for another 27%. Among 204 cesarean sections, SSI were confirmed for 40%, and some criteria were met for 27%. The extrapolated infection rates of 2.8% for breast procedures and 3.1% for cesarean section were similar to those reported by the National Nosocomial Infection Surveillance program but differ in representing predominantly outpatient infections. Claims data may complement other data sources for identification of surgical site infections following breast surgery and cesarean section.

Adult↗
PubMed1997

The importance of subjective claims management.

This article discusses the causes and effects of "subjective disability" on today's workforce and employers. As employees feel out of control with both their careers and demands placed upon them, the number of claims characterized by self-reported symptoms are increasing. Subjective disabilities include chronic syndrome, fibromyalgia, psychiatric claims and chronic pain. The author discusses creative strategies in case studies that have helped employers contain the costs of disability claims, while empowering the employee to take control of their own situation and return to work sooner.

Absenteeism↗
PubMed2002

Measuring deception: test-retest reliability of physicians' self-reported manipulation of reimbursement rules for patients.

This study examined the test-retest reliability of physicians' self-reported manipulation of reimbursement rules for patients. The test-retest reliability of self-report of three specific tactics were examined: (1) exaggerating the severity of patients' conditions, (2) changing a patient's official (billing) diagnosis, and (3) reporting signs or symptoms that patients did not have. The reliability of a scaled summary measure of physicians' manipulation of reimbursement rules was also assessed. Overall, the authors found high levels of test-retest agreement across all three items and the summary measure. These findings suggest that self-report can be used to produce reliable data on this controversial issue. Specifically, the three items reported here can be used to produce a reliable summary measure of physicians' manipulation of reimbursement rules to help patients obtain care that physicians perceive as necessary.

Deception↗
PubMed2004

The operative note as billing documentation: a preliminary report.

Certified professional coders from a multispecialty academic surgical practice used operative notes to identify 10 of the most common deficiencies for reimbursement of services. These 10 deficiencies were then used as evaluation criteria to audit the operative notes used as billing documentation. Twenty-four per cent of operative notes contained no deficiencies, whereas the remaining 76 per cent contained one or more audit criteria deficiencies. The three most common deficiencies identified included an incomplete description of all surgical procedures performed (56%), an inadequate description of the indications for procedures (49%), and only 45 per cent of the operative notes were dictated within 24 hours of the procedure. Thirty-nine per cent were dictated by faculty surgeons, whereas 61 per cent were dictated by surgical residents. Twenty-nine per cent of the operative notes that were dictated by faculty surgeons contained no deficiencies as compared with 20 per cent of the operative notes that were dictated by surgical residents. For a multispecialty academic surgical practice, the operative note is the document of justification for 75 per cent of revenue generated. We conclude that 1) the operative note represents the most important document for justification of reimbursement for surgical services, 2) surgeons should reassess the operative note as a billing document and provide the information necessary to expedite reimbursement, 3) surgical residents should be instructed in the details of an operative report as a billing document, and 4) most of the information needed in the operative note for billing purposes is simple and straightforward data that is important not only for reimbursement but also from a medico-legal and medical records standpoint.

Humans↗
PubMed2002

Patterns of oral care in dental school and general dental practice.

This study compared patterns of oral care provided by predoctoral dental students for patients seeking treatment at the University of Washington (UW) with patterns reported for general dental offices by the Washington Dental Service (WDS). Dental care included about 5 million services provided to 880,317 patients by 2,803 WDS general dentists and about 45,600 dental services provided to 9,488 patients by 155 UW dental students during 1999. There was high fidelity between databases and randomly surveyed patient records for treatment provided in both UW (95 percent) and WDS (97 percent) populations. While patient age patterns were generally similar, UW students completed more procedures for young children and for adults older than seventy-four years but completed fewer procedures for age groups of from thirteen to eighteen and from forty-five to fifty-four than general dental offices. The relative mix of all services completed by UW and WDS providers was similar (ANOVA, P=0.82). Within categories of service, the percentage of total services completed by students compared to those submitted by community dentists to WDS was about the same for examinations, radiographs, fluoride and sealants, amalgams, composites, single crowns, and endodontics. The percentage of total procedures completed showed a greater emphasis by UW students on inlays/onlays, dentures, extractions, and periodontal maintenance, and lesser experience with implants, orthodontics, sedation, and emergency procedures than general dental offices. We conclude that the relative distribution of clinical services provided by UW dental students is comparable to those procedures reported to WDS by dental offices in the adjacent community.

Adolescent↗
PubMed2002

Occupational carbon monoxide violations in the State of Washington, 1994-1999.

Occupational exposure to carbon monoxide continues to cause a number of injuries and deaths. This study reviewed the State of Washington OSHA inspection records for occupational safety or health violations related to carbon monoxide for the time period 1994-1999 to assess the agency's efforts and further identify and characterize causative factors. Inspection data were also compared with carbon monoxide claims data from a companion study to determine if the agency was visiting the most at risk work operations. Inspections were identified by searching computerized violation texts for "carbon monoxide" or "CO." The study found 142 inspections with one or more carbon monoxide violations. Inspections were spread over 84 different 4-digit Standard Industrial Classification codes. Most inspections were initiated as a result of a complaint or other informant. Inspections were predominantly in construction and manufacturing, whereas carbon monoxide claims were mores evenly distributed between the major industries. Inspections also may have failed to find violations for some types of equipment responsible for carbon monoxide claims. Forklifts were the source of carbon monoxide most often associated with a violation, followed by compressors for respirators, auto/truck/bus, and temporary heating devices. Inspections in response to poisonings found common factors associated with lack of recognition and failure to use or maintain equipment and ventilation. Some work sites with one or more poisonings were not being inspected. Only 10 of the 51 incidents with industrial insurance claim reports of carboxyhemoglobin at or above 20 percent were inspected. Further, it was found more preventive efforts should be targeted at cold storage operations and certain warehouse and construction activities. It is proposed that more specific standards, both consensus and regulatory, would provide additional risk reduction. Reliance upon safe work practices as a primary method of control in the use of fuel-powered equipment in cold storage or other enclosed and unventilated environments needs to be prohibited. The study further demonstrates how inspection and industrial insurance records can assist with preventive efforts and better focus an agency's efforts.

Air Pollutants, Occupational↗
PubMedDate not supplied

The cost of health insurance administration in California: estimates for insurers, physicians, and hospitals.

Administrative costs account for 25 percent of health care spending, but little is known about the portion attributable to billing and insurance-related (BIR) functions. We estimated BIR for hospital and physician care in California. Data for physician practices came from a mail survey and interviews; for hospitals, from regulatory reporting; and for private insurers, from a consulting company. Private insurers spend 9.9 percent of revenue on administration and 8 percent on BIR. Physician offices spend 27 percent and 14 percent, and hospitals, 21 percent and 7-11 percent, respectively. Overall, BIR represents 20-22 percent of privately insured spending in California acute care settings.

California↗
PubMed1979

Survival following renal transplantation in Saskatchewan, 1970--74: follow-up study using medical insurance records.

The patient history file of a medical care insurance plan can be used for statistical purposes in many ways. This is illustrated by the use of the records of the Saskatchewan Medical Care Insurance Commission to study the survival of patients receiving kidney transplants in the period 1970--74. During this period 48 males and 23 females received at least one renal transplant; these patients represented 34% of all males and 28% of all females undergoing regular renal dialysis. These period prevalence estimates are consistent with calculations based on incidence and point prevalence reported elsewhere. Life-table calculations showed the 4-year survival rate following first kidney transplantation in Saskatchewan to be 45% for all patients, 55% for those less than 45 years of age and 26% for those 45 years of age or older.

Actuarial Analysis↗
PubMedDate not supplied

Coding for effective denial management.

Nearly everyone will agree that accurate and consistent coding of diagnoses and procedures is the cornerstone for operating a compliant practice. The CPT or HCPCS procedure code tells the payor what service was performed and also (in most cases) determines the amount of payment. The ICD-9-CM diagnosis code, on the other hand, tells the payor why the service was performed. If the diagnosis code does not meet the payor's criteria for medical necessity, all payment for the service will be denied. Implementation of an effective denial management program can help "stop the bleeding." Denial management is a comprehensive process that works in two ways. First, it evaluates the cause of denials and takes steps to prevent them. Second, denial management creates specific procedures for refiling or appealing claims that are initially denied. Accurate, consistent and compliant coding is key to both of these functions. The process of proactively managing claim denials also reveals a practice's administrative strengths and weaknesses, enabling radiology business managers to streamline processes, eliminate duplicated efforts and shift a larger proportion of the staff's focus from paperwork to servicing patients--all of which are sure to enhance operations and improve practice management and office morale. Accurate coding requires a program of ongoing training and education in both CPT and ICD-9-CM coding. Radiology business managers must make education a top priority for their coding staff. Front office staff, technologists and radiologists should also be familiar with the types of information needed for accurate coding. A good staff training program will also cover the proper use of Advance Beneficiary Notices (ABNs). Registration and coding staff should understand how to determine whether the patient's clinical history meets criteria for Medicare coverage, and how to administer an ABN if the exam is likely to be denied. Staff should also understand the restrictions on use of ABNs and the compliance risks associated with improper use. Finally, training programs should include routine audits to monitor coders for competence and precision. Constantly changing codes and guidelines mean that a coder's skills can quickly become obsolete if not reinforced by ongoing training and monitoring. Comprehensive reporting and routine analysis of claim denials is without a doubt one of the greatest assets to a practice that is suffering from excessive claim denials and should be considered an investment capable of providing both short and long term ROIs. Some radiologists may lack the funding or human resources needed to implement truly effective coding programs for their staff members. In these circumstances, radiology business managers should consider outsourcing their coding.

Current Procedural Terminology↗
PubMed2005

Effects of electronic prescribing on formulary compliance and generic drug utilization in the ambulatory care setting: a retrospective analysis of administrative claims data.

OBJECTIVE: Electronic prescribing (e-prescribing) provides formulary information at the point of care. The objective of this study was to assess the effects of e-prescribing on formulary compliance and generic utilization. METHODS: This was a retrospective analysis of pharmacy claims data from a large national managed care organization. A sample of 95 providers using predominantly e-prescribing was randomly selected (e-prescriber group). A matched sample of 95 traditional prescribers was selected (traditional prescriber group), matched to the e-prescriber group by zip code and medical specialty. A total of 110,975 paid pharmacy claims, for the 12 months from August 1, 2001, through July 31, 2002, were analyzed to assess the effect of e-prescribing on formulary compliance and generic utilization. All paid pharmacy claims were examined for each group; for the e-prescriber group, this included all claims, not just those prescribed using an e-prescribing device. A written qualitative survey was distributed to physicians and office managers to assess e-prescribing usage, sources of formulary information, and effects of e-prescribing on office resources. RESULTS: Both predominantly e-prescribers and traditional prescribers demonstrated high levels of formulary compliance, 83.2% versus 82.8%, respectively (P=0.32). Formulary compliance for these groups did not differ from the overall prescriber population (82.0%). There was not a difference in generic drug utilization rates between e-prescribers and traditional prescribers (absolute rates 37.3% versus 36.9%, P=0.18). Qualitative survey responses supported previously reported research indicating reductions in calls both to and from pharmacies for prescription orders. CONCLUSIONS: An examination of paid pharmacy claims from a large, national managed care organization demonstrated no differences between predominantly e-prescribers and traditional prescribers in measures of formulary compliance or generic drug utilization. Future studies should examine keystroke data at the point of care to observe more detail about drug selection methods.

Ambulatory Care Information Systems↗
PubMed2003

Support for physician deception of insurance companies among a sample of Philadelphia residents.

BACKGROUND: Some physicians seem to be willing to sanction deception of insurance companies. Little is known about public attitudes regarding this practice. OBJECTIVE: To assess public attitudes regarding physician deception of insurance companies. DESIGN: Cross-sectional survey using clinical vignettes. SETTING: Philadelphia County Courthouse, Philadelphia, Pennsylvania. PARTICIPANTS: Convenience sample of 700 prospective jurors. MEASUREMENTS: Participants were asked whether, in response to restriction of health care, a physician should 1) accept restriction, 2) appeal restriction, or 3) misrepresent a patient's condition to obtain the desired service. The proportion of respondents reporting that the physician should misrepresent a patient's condition was determined. RESULTS: 26% of respondents sanctioned deception, 70% supported appealing, and 4% supported accepting the insurance company decision. Among the 27% of respondents believing physicians have inadequate time to appeal coverage decisions, 50% sanctioned deception. CONCLUSIONS: Sanctioning of deception was substantial in this sample of prospective jurors. Preferences regarding insurance company deception are related to perceptions of physician workload and may further pressure physicians struggling to balance advocacy with honesty.

Adult↗
PubMedDate not supplied

The history of injury and industrial disease rates in British Columbia from 1950 to 1996.

The purpose of this investigation is to describe changes in industrial injury and disease rates in British Columbia between 1950 and 1996. Data on injury and disease rates were abstracted manually from WCB Annual Reports for the years 1950 through 1996. A number of interesting patterns emerge. Death report rates declined by 79% during the study period. Injury report rates also declined, although less dramatically, by 29%, over the 46-year study period with much of the decrease occurring prior to 1970. Accepted claims for impact injuries declined prior to the 1970s. At the same time claims for strain injuries began to increase with the pace of increase accelerating after 1970. A similar pattern was observed for industrial disease as the incidence of strain-based disease claims also increased rapidly after 1970. This pronounced trend towards "strain-related" injuries and disease creates new challenges for adjudication and prevention. The identification of work organizational and job structural features which contribute to strain injury and disease and the elucidation of the relationship between these conditions and "physical" strain injuries should be a priority for injury epidemiologists and WCB.

Accidents, Occupational↗
PubMed2003

Clinical integration of billing for a pediatric nephrology and transplant program.

PURPOSE: To develop and implement a billing process that fully integrates all activities of a pediatric nephrology and transplant program, by facilitating and coordinating data from patients, physicians, hospitals, and third-party billing services to maximize revenues. METHODS: Financial operations were analyzed via a randomized audit of patient charts that focused on office procedures and revenue collection. Results based on monthly reports documenting revenue received and outstanding, procedures billed, and patient registration accuracy. RESULTS: The combination of improvements in patient registration, chart documentation, new billing sheets with procedure and diagnosis codes, physician in-service education, upgraded charges, and the recredentialing of all practice physicians realized an increase in revenue collections from 18% in 2000 to 89% in 2001. CONCLUSION: The need to integrate and coordinate information is vital for both billing accuracy and revenue collections. Integration of clinical services and billing procedures has maximized performance, profitability, and accuracy while decreasing administrative time and costs.

Child↗