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At least 163 records · Page 9Linked to original sources
PubMed2005

Treatment duration and cost of work-related low back pain in Korea.

The purpose of this study is to present the information on the duration of treatment and the cost of work-related low back pain. Using the compensation-database for 1997 work-related low back pain (n=9,277), this study estimated the duration of treatment, the cost of work-related low back pain, the relationship between them, and probability of being off treatment at different intervals. The mean and the median of the treatment duration are 252.6 days and 175 days. The mean and the median of the cost of total insurance benefit are 37,700,000 won and 14,400,000 won. The treatment duration of 51% of the study subjects was less than 6 months and their cost accounted for 10.2% of the total insurance benefit. The subjects who were treated more than 24 months were 5.8% but it accounted for 29.2% of the cost. It was found that approximately 50% of the subjects who will remain on treatment at the end of n months would be off treatment at the end of n+5 months. This study presents the point in time when the low back pain (LBP) workers need to prepare to return to work by forecasting their off-treatment period. From the treat duration and cost perspectives, this study may be utilized as evidence for active management of work-related LBP.

Absenteeism↗
PubMed2004

Social Security disability insurance benefits-eligibility. Barnhart, Commissioner of Social Security v. Walton.

SSA's interpretation of the Social Security Act and its regulation requiring that eligibility for benefits requires that an applicant be both impaired and unable to engage in substantial gainful activity (work) for at least 12 months was permitted by the act and the regulation was lawful. SSA was entitled to the benefit of hindsight, and even though an individual might have been awarded benefits under the act if the decision were made before the end of 12 months because the impairment and inability to work could be expected to last at least 12 months, it could deny benefits when it makes its decision after 12 months from the onset of the impairment and knows the applicant was able to work after 11 months.

Eligibility Determination↗
PubMed2006

State-mandated benefit review laws.

OBJECTIVE: To determine which states have laws that require the review of mandated health insurance benefits and describe the various approaches states take in reviewing mandated benefits, as stated in the mandated benefit review (MBR) laws. DATA SOURCES: We queried online databases of the individual state statutes and reviewed the state statutes and state legislative agendas for all 50 states and Washington, DC to identify those states with active MBR laws as of September 2004. STUDY DESIGN: We reviewed the identified MBR laws to catalog their various components. The components chosen for this analysis include: general review strategy, designated reviewers, time frame for conducting reviews, criteria used in the review, requirements to use actuaries, sources of funding, and state data collection systems. Two of the authors independently created analysis categories and coded the MBR laws to document details on the major components of the laws. PRINCIPAL FINDINGS: We identified 26 state MBR laws active as of September 2004. A majority of the MBR laws specified a prospective review approach and only one law used an exclusively retrospective review approach. A substantial amount of variation was found with regards to the designated reviewers, time frames for conducting reviews, and criteria used in the review. Few states specified the use of actuaries, sources of funding, and state data collection systems. CONCLUSIONS: The number of states that have enacted MBR laws has increased substantially in recent years, however, different states have structured the review of mandated benefits differently, according to the values and perceived needs of the state legislatures. It is important that states increasingly consider a broader scope of review criteria so state decision makers can position themselves to mandate only those benefits that add real value to the state's health care system.

Insurance Benefits↗
PubMed1978

The psychiatrist and health insurance claims review.

Expanded health insurance benefits for the treatment of mental illness have obliged psychiatrists to devote more time to justifying psychiatric treatment to claims reviewers. The author, drawing from experience in utilization review and peer review, summarizes factors contributing to the denial of payment for psychiatric services by health insurers, and gives practical advice on protecting against claims denials and on the process of appealing denials. Psychiatrists should make greater use of peer review committees to justify legitimate treatment services in the face of claims denials. Greater coverage for psychiatric treatment under national health insurance will increase the psychiatrist's responsibility for public accountability. This accountability will require better communication between psychiatrists and claims reviewers.

Insurance Benefits↗
PubMed1992

Medicare program; HHS' recognition of NAIC Model Standards (National Association of Insurance Commissioners) for regulation of Medigap policies--HCFA. Notice.

This notice contains a list of the ten standardized Medicare supplemental insurance benefit packages that may be offered to Medicare beneficiaries consistent with the requirements of section 1882 of the Social Security Act (the Act), as amended by sections 4351 through 4358 of the Omnibus Budget Reconciliation Act of 1990. This list is included in section 9 of the Model Regulation adopted by the National Association of Insurance Commissioners (NAIC) on July 30, 1991, which is reprinted at the end of the notice. Until the publication of this list, certain provisions of section 1882 of the Act relating to this type of insurance were inapplicable to sellers who are not also the issuers of health insurance policies being sold to Medicare beneficiaries.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1997

Temporomandibular joint litigation: resolving issues of medical necessity and contract ambiguity.

Courts routinely award coverage for TMJ disorders under medical plans, despite exclusionary language and evidence that the insured failed to disclose preexisting treatment as required by the plan and neglected to attempt more conservative treatment first. Such decisions adversely affect both the health carrier and the plan participants. Various states have enacted legislation mandating coverage of TMJ; however, TMJ issues still exist and will remain a frequent topic for litigation until the judiciary recognizes that validating contract language ultimately benefits insureds as consumers and reinforces the integrity of the industry as a whole.

Humans↗
PubMed1994

Patients' rights after health care reform: who decides what is medically necessary?

President Clinton's Health Security Act entitles individuals not to unlimited health care, but to a package of defined insurance benefits with specific exclusions and limitations. Like virtually all reform proposals, it would limit covered benefits to services that are medically necessary. If health reform is to control costs, not all medically necessary care can be covered. In the absence of a generally accepted definition of medical necessity, many services will not be guaranteed to all patients unless they are explicitly covered in the federal legislation or regulations. Without a federal definition of medical necessity or regulations listing covered services, health insurance plans will retain the primary authority to decide what is medically necessary for their patient subscribers.

Cost Control↗
PubMed2000

Rural health care and the nurse anesthetist.

As they work in all types of practice arrangements and settings with and without anesthesiologists, certified registered nurse anesthetists have been and continue to be the principle anesthesia providers in rural hospitals in the United States. As such, they are responsible for providing anesthesia services to about 1 quarter of the US population that resides in rural and frontier areas of this country. Rural health care is characterized by its necessity to provide a broad array of services with lesser resources than are typically available in metropolitan or urban areas. The rural population is characterized as having a higher proportion of elderly people and children under the age of 18, a higher incidence of chronic diseases, a lower mortality rate (albeit a slightly higher infant mortality rate), and a 40% higher mortality rate resulting from accidents. Rural residents are poorer and less likely to have job-related health insurance benefits or Medicare supplemental insurance. Despite the significant rise in the number of anesthesiologists in the past 10 to 15 years, there is no evidence that they are attracted to practice in these areas. As sole anesthesia providers in many of these rural hospitals, rural CRNAs have both common and unique problems and issues that confront them. However, from available reports, their communities are satisfied with their services, providing evidence of the capability of CRNAs to function satisfactorily without the anesthesiologist.

Hospitals, Rural↗
PubMedDate not supplied

Toward a health care financing strategy for the nation. Report of the National Health Policy Seminar.

All people in the United States have a need for access to comprehensive high quality health care. Such need is so universal and fundamental, not only to personal health, but also to equitable pursuit of all opportunity in a modern and just society, that it is viewed increasingly in the context of rights. Although the current array of health financing programs--Medicare, Medicaid, employer-based medical care insurance benefits, private medical care insurance, and other current insurance methods--have major accomplishments to their credit in providing access to care, the United States falls short in guaranteeing that conceptual right. The result is that 35 to 40 million people in the United States have no insurance coverage at all for medical care expenses, and an unknown number of people have coverage that is grossly inadequate. In addition, our current medical care system is characterized by: significant barriers to equitable access to care, apart from lack of coverage of the direct costs; major deficiencies in services for rehabilitation, long-term care, and home care; extreme variablity in the utilization and quality of care. We also must acknowledge failures in fundamental programs that directly affect the health of our people, such as health manpower, housing, education, and protection against occupational and environmental hazards. However, these matters are outside the purview of this statement. We propose a program, under the leadership of the federal government, with state and local government and the private sector having significant roles to play, that will respond to these shortcomings in our health care system. The program would finance health services comprehensively and equitably, minimize duplication, inefficiency, and the uneven quality of care, and would emphasize health promotion and disease prevention.

Capital Financing↗
PubMed2002

The use of nursing home and assisted living facilities among private long-term care insurance claimants: the experience of disabled elders.

Little is known about individuals in nursing homes (NHs) and assisted living facilities (ALFs) who receive private long-term care (LTC) insurance benefits. No one knows whether claimants and/or their families feel they are getting good value for their premiums, or whether the presence of private insurance influences the type of care people get. This brief provides descriptive information on disabled private LTC insurance policyholders receiving LTC benefits in these settings, comparing them to institutionalized elders who lack such insurance. The information shows that private LTC insurance benefits are targeted to individuals with significant functional and/or cognitive impairments; that claimants are satisfied with their policies although many report unmet needs; and that private LTC insurance gives claimants access to alternatives to nursing home care.

Aged↗
PubMed2006

The California Cost and Coverage Model: analyses of the financial impacts of benefit mandates for the California legislature.

OBJECTIVE: To produce cost estimates of proposed health insurance benefit mandates for the California legislature. DATA SOURCES: The 2001 California Health Interview Survey, 2002 Kaiser Family Foundation/Health Research and Education Trust California Employer Health Benefits Survey, Milliman Health Cost Guidelines, and ad hoc surveys of large health plans were used. STUDY DESIGN: We developed an actuarial model to estimate short-term (1 year) changes in utilization and total health care expenditures, including insurance premiums and out-of-pocket expenditures, if insurance mandates were enacted. This model includes baseline estimates of current coverage and total current expenditures for each proposed mandate. PRINCIPAL FINDINGS: Analysis of seven legislative proposals indicated 1-year increases in total health care expenditures among the insured population in California ranging from 0.006 to 0.200 percent. Even when proposed mandates were expected to reach a large target group, either utilization or cost was sufficiently low to keep total cost increases minimal. CONCLUSIONS: Our ability to develop a California-specific model to estimate the impacts of proposed mandates in a timely fashion provided California legislators during the 2004 legislative session with more-detailed coverage and cost information than is generally available to legislative bodies.

Actuarial Analysis↗