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At least 1,549 records · Page 86Linked to original sources
PubMed1994

Medicare program: data, standards and methodology used to establish fiscal year 1993 budgets for fiscal intermediaries and carriers--HCFA. Final notice.

This notice is published in accordance with sections 1816(c)(1) and 1842(c)(1) of the Social Security Act which requires us to publish the final data, standards and methodology used to establish budgets for Medicare intermediaries and carriers. It announces that we are adopting as final, and responds to comments about, the data, standards, and methodology we proposed to use to establish Medicare fiscal intermediary and carrier budgets for the fiscal year (FY) 1993, beginning October 1, 1992.

Budgets↗
PubMed1998

Federal employees health benefits program: disenrollment--OPM. Final rule.

The Office of Personnel Management (OPM) is issuing final regulations that are consistent with existing administrative procedures requiring employing offices to provide information about enrollees in the Federal Employees Health Benefits (FEHB) Program to the carriers of the FEHB plans in which they are enrolled. Carriers are also required to use the information provided by employing offices to reconcile their enrollment records. These regulations will regularize the conditions that would allow carriers to disenroll individuals when their employing office of record does not show them as enrolled in the carrier's plan and the carrier is otherwise unable to verify the enrollment. The purpose of these regulations is to facilitate reconciliation of carrier and employing office enrollment records, especially in cases where the carrier has not previously received a notice showing an enrollment no longer is valid.

Government Agencies↗
PubMed2001

Harry and Louise and health care reform: romancing public opinion.

The question whether the "Harry and Louise" campaign ads, sponsored by the Health Insurance Association of America (HIAA) during the 1993-1994 health care reform debate, influenced public opinion has particular relevance today since interest groups are increasingly choosing commercial-style mass media campaigns to sway public opinion about health policy issues. Our study revisits the issue of the Harry and Louise campaign's influence on public opinion, comparing the ad campaign's messages to changes in opinion about health care reform over a twenty-six-month period in Oklahoma. Looking at the overall trends just prior to the introduction of the Harry and Louise campaign, public opinion was going in the "wrong" direction, from the HIAA perspective. Moreover, public opinion continued in the wrong direction until the mid-point of the campaign. However, in either the turning point of the campaign in terms of message content and tone or in the lag period following it, public opinion reversed on each health reform issue and returned to pre-campaign levels. It appears from these findings that the campaign captured public opinion when support for issues that were unfavorable to HIAA members was increasing and turned public opinion back to pre-campaign levels. The campaign may result in many more such marriages of political interest groups and commercial advertisers for the purpose of demobilizing public support for health policy initiatives that are unfavorable to special interests.

Adult↗
PubMed1994

Medicare program: data, standards, and methodology used to establish fiscal year 1994 budgets for fiscal intermediaries and carriers--HCFA. Final notice.

This notice is published in accordance with sections 1816(c)(1) and 1842(c)(1) of the Social Security Act which require us to publish the final data, standards, and methodology used to establish budgets for Medicare intermediaries and carriers. In this notice, we respond to the comments received in response to our notice of October 5, 1993 and we announce the adoption of the proposed data, standards, and methodology that we used to establish the Medicare fiscal intermediary and carrier budgets for fiscal year (FY) 1994, beginning October 1, 1993, as final and without revision.

Budgets↗
PubMed1998

Federal Employees Health Benefits Program improving carrier performance; conforming changes--OPM. Final rule.

The Office of Personnel Management (OPM) is issuing a final regulation that implements OPM's initiative to ensure high quality customer service to its enrollees in the Federal Employees Health Benefits (FEHB) Program by establishing a performance evaluation program that will hold community-rated carriers accountable for their performance. The regulation would enable OPM to better manage carriers' performance in key contract areas, including customer service measures, information and reporting requirements, and significant events that might affect service to enrollees.

Government Agencies↗
PubMed1999

Healthcare transition managers make market exits easier for insurers.

Insurers have been struggling to meet and maintain their profit margins on the health insurance business they underwrite. As a result, many have exited or are contemplating exiting from the health insurance market. At the same time, managed care organizations are seeking ways to augment their enrollment base and satisfy investor expectations. Insurers that wish to transfer their health insurance business to other carriers and managed care organizations that are interested in accepting this business have turned to a new type of healthcare financing company--the healthcare transition manager--to facilitate the transaction. Part broker, part matchmaker, and part administrative coordinator, these companies make it possible for commercial insurers to exit the health insurance market without undue hardship to enrollees or the managed care plans that assume risk for their care.

Consultants↗
PubMed1993

Medicare program; data, standards and methodology used to establish fiscal year 1992 budgets for fiscal intermediaries and carriers--HCFA. Final notice.

This notice is published in accordance with sections 1816(c)(1) and 1842(c)(1) of the Social Security Act which require us to publish the final data, standards and methodology used to establish budgets for Medicare intermediaries and carriers. It announces that we are adopting as final without revision proposed data, standards, and methodology used to establish Medicare fiscal intermediary and carrier budgets for the fiscal year (FY) 1992, beginning October 1, 1991. It also contains our response to public comments on the proposal.

Budgets↗
PubMed1985

Medicare program; criteria and standards for evaluating intermediary and carrier performance during fiscal year 1986--HCFA. General notice with comment period.

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program for fiscal year 1986. The results of these evaluations are considered whenever we enter into, renew, or terminate an intermediary or carrier agreement or take other contract actions; assign or reassign providers of services to an intermediary; or designate regional or national intermediaries.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1996

Managed competition and California's health care economy.

There is evidence in California of a broad decline in health care costs to employment groups adopting managed care and managed competition--premium reductions up to 10 percent. National comparisons and utilization data generally confirm the beginning of lower costs. Large California medical groups and health systems have responded to pressure by finding ways to reduce costs and improve quality. While examples are encouraging, there is room for improvement. Two levels of competition have emerged and continue to evolve: carrier competition and delivery system competition. Each model has strengths and limitations, but the existing mix is driving down costs.

California↗
PubMed1994

Medicare program; criteria and standards for evaluating intermediary and carrier performance during FY 1994--HCFA. General notice.

In the September 30, 1993 issue of the Federal Register, we published a general notice with comment period describing the criteria and standards for evaluating intermediary and carrier performance in administering the Medicare program during FY 1994. This notice amends that document to require that contractors certify the accuracy and completeness of the information submitted to HCFA with respect to the evaluation process.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1987

Medicare program; criteria and standards for evaluating intermediary and carrier performance during fiscal year 1988--HCFA. General notice with comment period.

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program for the fiscal year beginning October 1, 1987. The results of these evaluations are considered whenever we enter into, renew, or terminate an intermediary or carrier contract or take other contract actions; assign or reassign providers of services to an intermediary; or designate regional or national intermediaries. In addition, this notice describes the methodology used for identifying contractors for competitive replacement under section 2326 of the Deficit Reduction Act of 1984.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1994

ME changes: effects on patient care delivery.

The Health Care Financing Administration consolidated Durable Medical Equipment (DME) processing into four regional DME carriers for Medicare. These four DMERCs Durable Medical Equipment Regional Carriers (DMERCs) will process claims more accurately, reduce variations in coverage decisions, and decrease the opportunities for fraud. Taken in its entirety, the DME regionalization process is a major step toward achieving nationally consistent expectations for quality of care.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1990

Medicare surgical global fees: the relationship between included services and payment.

This paper documents how extensively the component services Medicare carriers include in their global fees vary for four common operations. Although payment for each of the operations also varies substantially among Medicare carrier areas, differences in the extent of services included in the surgical global fee do not contribute to explaining the variations in payment. The recently enacted Medicare fee schedule based on resources can rationalize the current pattern of payments, but only if a uniform global service policy is implemented.

Fee Schedules↗
PubMed1991

Beneficiary complaints, provider numbers and carrier shopping: Medicare contractor operations.

The number of Medicare claims processed annually will double in the next 10 years, making it imperative that contractors review claims accurately and ensure that payments are made only for medically necessary, high-quality care. Effective identification and prosecution of fraud and abuse in the Medicare program will depend on a cooperative effort between Medicare contractors, the Health Care Financing Administration, and the Office of Inspector General.

Centers for Medicare and Medicaid Services, U.S.↗
PubMedDate not supplied

Insolvency risk in health carriers: innovation, competition, and public protection.

This paper reviews the framework of regulatory and managerial devices that have evolved in response to the special dangers to the public posed by insolvency of health carriers. These devices include "prudential" measures designed to decrease the likelihood of insolvency, and measures to "protect enrollees" in the event that insolvency occurs nevertheless. It also reviews the current debate over how this framework should be adapted to new forms of risk-bearing entities, especially provider-sponsored networks engaged in direct contracting with purchasers of coverage. Parallels to solvency concerns in the banking industry are explored.

Bankruptcy↗
PubMed1991

Health care financing for all Americans.

Access to health care financing can be achieved by using a combination of public and private initiatives aimed at every American who wants access to health care but is currently denied access. Small-employer market reforms that would guarantee the availability and affordability of coverage to small employers and their employees should be enacted. A private, not-for-profit reinsurance mechanism should be established to absorb losses for high-risk individuals and high-risk employer groups insured by carriers. State risk pools should be established to provide coverage to high-risk individuals who cannot obtain coverage through an employer. Tax assistance should be provided to small employers who make health care coverage available to their employees. The Medicaid program should be extended to cover all poor and near-poor Americans and to provide primary and preventive care for the near poor.

Cost Control↗
PubMed1986

Medicare program; reasonable charge limitations--HCFA. Final rule with comment period.

This final rule implements section 9304(a) of the Consolidated Omnibus Budget Reconciliation Act of 1985 which enacted section 1842(b)(8) of the Social Security Act (Act). In accordance with section 1842(b)(8) of the Act, we specify the circumstances under which HCFA or its Medicare Part B carriers will consider establishing special reasonable charge payment limits for services (including supplies and equipment) reimbursed under Part B of the Medicare program. The rule describes the factors HCFA or a carrier will consider and the procedures it will follow in establishing them. The limits would be either an upper limit to correct a grossly excessive charge or a lower limit to correct a grossly deficient charge. In either case, the limit would be either a specific dollar amount, or a special method used in determining reasonable charges to be allowed for a particular service or category of service. The purpose of this rule is to establish a stronger framework for setting special reasonable charge limits for services when the standard reimbursement methodology results in payments that are grossly excessive or deficient. A related purpose is to protect the Medicare program from excessive outlays and to prevent any adverse effects on both Medicare beneficiaries and consumers in general that we believe would result from a lack of such limits. The rule also will protect suppliers from reimbursement that is grossly deficient.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1998

Effects of providing comprehensive ambulatory services to children with chronic conditions.

OBJECTIVE: To document the effects of a comprehensive program of care on the resource utilization and cost of care for children with chronic conditions. DESIGN: Descriptive study of 10715 admissions between 1984 and 1995 with analyses of costs based on charges. Comparisons were made with data from a national consortium of academic medical centers and from a national survey of hospitals. A 2-week survey of staff was conducted to identify their use of time in the care of these patients. PATIENTS: Children aged birth through 18 years meeting International Classification of Diseases, Ninth Revision, Clinical Modification criteria for chronic conditions. Patients with acute conditions were used as controls. INTERVENTION: A program of expanded care funded since 1989 by a regional insurance company. RESULTS: Between 1984 and 1995, mean length of stay for children with chronic conditions decreased from 83.9 to 10.6 days; mean annual admissions decreased from 2796 to 1622. Median hospital inpatient charges, adjusted for cost of living, decreased from $26.1 to $14.6 million. A $77.7 million savings occurred for inpatient care, with total expenditures from the insurance program of $3.6 million (a 21:1 ratio). Almost half the professional activities provided for these children were for services that could not be reimbursed in a fee-for-service model. Median adjusted inpatient charges were lower in Rochester, NY ($8746) than in other academic medical centers ($12773) or in a national survey of hospitals ($12462), and fewer children were readmitted within 30 days in Rochester (12.7%) than in other academic medical centers (15.0%). CONCLUSIONS: An investment of funds by a regional insurance company was associated with reduced costs, admissions, and lengths of stay for children with chronic conditions, and resulted in significant savings for the company. This model may be applicable to other centers.

Adolescent↗