Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “Insurance Claim Reporting”

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 163 records · Page 9Linked to original sources
PubMed1992

Coding and reimbursement of primary care biopsy and destruction procedures.

Current medical practice requires physicians to accurately report services provided to patients. Billing for destruction of benign and malignant lesions and for surgical, needle, and endoscopic biopsy procedures involves the selection of specific 1992 Current Procedural Terminology (CPT) codes. Payment for these procedures by third-party payers often requires the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding for neoplastic lesions. This review explains the proper codes to use in identifying common biopsy and destruction procedures performed by primary care physicians. The Health Care Financing Administration's relative value units and one state's published Medicaid payment rates are included for each procedure code. Instructions for selecting site-specific biopsy and destruction codes are provided.

Abstracting and Indexing↗
PubMed2004

Physicians' interactions with third-party payers: is deception necessary?

Published reports indicate that physicians sometimes use deceptive tactics with third-party payers. Many physicians appear to be willing to deceive to secure care that they perceive as necessary, particularly when illnesses are severe and appeals procedures for care denials are burdensome. Physicians whose practices include larger numbers of Medicaid or managed care patients seem more willing to deceive third-party payers than are other physicians. The use of deception has important implications for physician professionalism, patient trust, and rational health policy development. If deception is as widespread as these studies suggest, there may be serious problems in the medical profession and the health care financing systems at the interface between physicians and third-party payers. Deception may be a symptom of a flawed system, in which physicians are asked to implement financing policies that conflict with their primary obligation to the patient.

Deception↗
PubMedDate not supplied

Louisiana dentists' attitudes toward the dental Medicaid program.

PURPOSE: This study was performed to determine factors associated with Louisiana dentists' participation in the Dental Medicaid Program. METHODS: Surveys were mailed to all pediatric and general dentists as reported by the Louisiana State Board of Licensing. A second mailing was made to non-respondents. RESULTS: Surveys from 956 of 1,926 dentists (50%) were returned. Of 607 general dentists and 40 pediatric dentists who treated dental Medicaid-enrolled children in the past year, 269 (44%) and 18 (45%), respectively, treated all Medicaid-enrolled children. Newly graduated dentists were more likely to be actively enrolled than their more established counterparts (chi 2 = 10.67; p = 0.01). Medicaid reimbursement levels were viewed as "much less" than private fees by 62%, "less" by 33% and "the same" by 4% of the respondents. Broken appointments were the most prevalent reported problem (80%), followed by low fees (61%), patient non-compliance (59%), unreasonable denial of payments (57%), slow payment (44%), and complicated paperwork (42%). With the exception of the perceived importance of Medicaid reimbursement levels, active and inactive general and pediatric dentists' perceptions of the importance of Medicaid issues were not significantly different. These findings indicated that significantly more Medicaid-active general dentists who allocated 10% of their office visits to Medicaid-eligible children felt that slow payment (p = 0.002) and complicated paperwork (p < 0.001) were more important problems than general dentists who allocated less time to Medicaid-eligible children. CONCLUSIONS: Louisiana dentists' sources of dissatisfaction with Medicaid are similar to those of dentists in other states. Some of the issues are programmatic and are within the power of the dental Medicaid director and state legislature to address. Patient-related issues such as frequent broken appointments may be addressed by assigning case managers to Medicaid beneficiaries.

Adolescent↗
PubMed2003

Overview of inpatient coding.

The main classification-based and nomenclature-based coding systems used in the United States, as well as the process and importance of documenting in the patient record, are discussed. Hospital pharmacists usually have limited knowledge of and exposure to coding and reimbursement in the inpatient system. Coding allows for reporting of mortality data to the World Health Organization (WHO), reporting morbidity data in the U.S., and providing data for reimbursement from third-party payers to hospitals for services provided. Coded information is also the primary source for administrative management of medical services and a source of epidemiologic and statistical data from inpatient stays. In order to better understand inpatient coding and reimbursement, this article will discuss the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding system; the Healthcare Common Procedure Coding System (HCPCS); the process and importance of appropriate chart documentation; and the development of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) coding system. Coding in the inpatient setting enables hospital billing and provides statistical data for epidemiology and financial planning. The ICD-9-CM is a clinically modified version of the international ICD-9 system used for coding both diagnoses and procedures in the United States. Coding is derived from documentation found in the patient's chart. Appropriate documentation is key for quality and continuity of care and compensation for resources utilized. In the future the ICD-9-CM will be replaced by the 10th revision, ICD-10, which is already in use in many countries in Europe.

Abstracting and Indexing↗
PubMed2000

Whiplash-type neck distortion in restrained car drivers: frequency, causes and long-term results.

An analysis was made of 1176 whiplash-type neck distortions taken from a total of 3838 restrained car driver incident reports. The percentage of whiplash-type neck distortion among injured drivers increased from less than 10% in 1985 to over 30% in 1997. Most occurred in head-on crashes or crashes with multiple collisions; only 15% occurred in rear-end collisions. More than 1,000 questionnaires were sent to the injured to find out about the duration and type of complaints caused by their cervical spine injury. Although only 138 (12%) returned the questionnaire, which may not be a representative sample, a further analysis was carried out. Of the 138, 121 (88%) indicated that they had suffered or were still suffering from their symptoms. The percentages of the various complaints were as follows: pain (74%), tension (6%) and stiffness (5%) in the head (27%), neck (55%) and shoulder (8%). The duration of the complaints was longest after multiple collisions and when the onset of complaints was longer than 24 h after trauma. Women and elderly persons predominated slightly in the group with longer duration of complaints. A correlation between the severity of the accompanying injuries and duration of complaints was found. Lack of adequate follow-up for patients with less severe injuries posed considerable difficulties for this retrospective study. In order to better evaluate this problem, prospective studies are necessary, with documentation including diagnosis, treatments, complaint duration and type.

Accidents, Traffic↗
PubMed2002

The "Hassle Factor": what motivates physicians to manipulate reimbursement rules?

BACKGROUND: Some physicians are willing to misrepresent clinical information to insurance companies to circumvent appeals processes. Whether characteristics of appeals processes affect the likelihood of misrepresentation is unknown. This study sought to determine the relationship between the likelihood of a successful appeal, appeals process length, and severity of the health condition and physicians' willingness to sanction deception. METHODS: A random sample of 1617 physicians was surveyed by mail to assess their willingness to accept an insurance company restriction, to appeal the restriction, or to misrepresent the facts to an insurance company to obtain coverage for a patient. RESULTS: Most respondents would appeal (77%) rather than accept (12%) or misrepresent (11%) regarding a restriction on medically necessary care. Physicians' decisions were related to the likelihood of a successful appeal (chi(2) = 7.56; P =.02), the appeals process length (chi(2) = 8.53; P =.01), and the severity of the medical condition (chi(2) = 71.10; P<.001). A small but significantly larger number of physicians chose to misrepresent the facts to an insurer as the appeals process became more cumbersome. Among physicians asked about severe angina, their decisions were particularly affected by the hassle associated with appealing, being more likely to choose to misrepresent the facts to the insurer than to appeal as the hassle increased. CONCLUSIONS: Physicians are more willing to sanction deception when the appeals process is longer, the likelihood of a successful appeal is lower, and the health condition is more severe. Changes in the difficulty of appeals processes may ease the tensions physicians face regarding patient advocacy and honesty.

Analysis of Variance↗
PubMed1993

Risk of hospitalization for specific non-work-related conditions among laborers and their families.

To better describe patterns of nonoccupational morbidity among construction laborers and their dependents, two health insurance plans organized by local unions of the Laborers' International Union of North America provided their medical claims data for 1989. The observed numbers of hospital admissions were compared with the numbers expected, based on the age-sex-specific hospital discharge rates from the 1989 National Hospital Discharge Survey. Standardized morbidity ratios thus obtained showed excesses for alcohol and drug dependence, complications related to pregnancy, and several other conditions. Medical claims data are a very useful resource in epidemiologic and medical care research, but their use poses numerous challenges, mainly related to the accuracy of diagnostic recording, problems in comparing different health insurance plans, and confounding factors due to health insurance largely being a condition of employment. Nevertheless, the use of these data can provide specific hypotheses for further study.

Adolescent↗
PubMed1983

Identification of practice problems in dentistry.

This paper examines the use of dental insurance claim data for studying the dental care delivery system. Several research projects are described including investigations of the amount, types and causes of variation in dental practice patterns, the cost-effectiveness of different patterns of care in producing oral health, the feasibility of focused utilization review systems and the selection of continuing education topics and participants. The importance of these and other data information systems to the future practice of dentistry and medicine is stressed.

Dentistry↗
PubMed2004

Medical errors: the perspective of the insurer.

Errors in medicine have a significant impact upon the cost of health insurance in the United States. These errors may reflect a range of errors ranging from ineffective or futile care to inappropriate medical judgments to coding errors. These may be unintentional, but underlying all of these error-types is a failure of process stemming back to physician training. The commercial industries that pay for health insurance may be demanding a process approach and accountability structures in return for continued funding of health care services.

Delivery of Health Care↗
PubMedDate not supplied

Use of pharmacy claims databases to determine rates of medication adherence.

Failure to adhere to pharmaceutical therapy leads to poor clinical outcomes and substantially increased healthcare costs. Pharmacy claims databases contain all the information required to determine adherence to therapy for populations and individual patients, but extraction and analysis of these data are difficult and time-consuming. The Standardized Therapy Adherence Research Tool (START) converts pharmacy claims databases into a standardized format to rapidly obtain comprehensive adherence information that can be used to design interventions aimed at improving adherence rates.

Databases, Factual↗
PubMed2006

Follow-up costs up to 5 years after conventional treatments in patients with cartilage lesions of the knee.

In this retrospective cross-sectional study, we contacted patients who had been diagnosed with (and, if necessary, treated for) knee cartilage defects by arthroscopy at one of seven treatment centres in Germany between 1997 and 2001. In early 2003, patients completed a questionnaire on the health care resources they had used since the time of the arthroscopy. Based on this information, we determined follow-up costs. Data from a total of 1,708 patients were included in the final analysis. Of these, 1,070 were assigned to the initial operation (IO) group (61% men, 49+/-15 years; 39% women, 52+/-14 years) and 638 were assigned to the re-operation (RO) group (64% men, 44+/-13 years; 36% women, 47+/-14 years). The cumulative direct medical costs caused by knee complaints for the first 5 years following the arthroscopy were 1,984 Euro for the IO population and 4,203 Euro for the RO population. The cumulative indirect costs (i.e. costs associated with loss of productivity), however, amounted to 7,669 Euro and 15,265 Euro, respectively, and were thus almost four times as high as the cumulative direct costs. This is the first study that quantifies the considerable follow-up costs in patients who have undergone surgery for knee cartilage defects. As such, it may provide a yardstick for future treatments.

Adult↗
PubMed1992

Are radar detector users less safe than nonusers?

One hundred and seventy-four drivers who had purchased special insurance coverage during 1988-1989 for in-vehicle equipment that included a radar detector were compared to a similarly sized and sociodemographically stratified driver population random sample. It was found that the radar detector owners had significantly more accident claims and speeding convictions during the period 1986-1989 than those representing the general driver population.

Accidents, Traffic↗
PubMed1991

Canadian medical malpractice liability: an empirical analysis of recent trends.

The determinants of the frequency of Canadian malpractice claims, the proportion of claims that result in payment, and the severity of these claims are examined. Inter-specialty variation in the frequency of malpractice claims is almost entirely related to the differential performance of major surgery. Various legal doctrines concerning both compensation and liability appear responsible for approximately half of the upward trend in the propensity to initiate malpractice litigation. We believe that the remaining explanations for growth in claims frequency are changes in social attitudes toward risk-bearing, increasing social distance between patients and physicians, and innovations in medical technology.

Canada↗
PubMed1984

No-fault insurance for vaccine related injuries. Jeffrey O'Connell proposes an alternative insurance scheme for vaccine-injury victims.

Under tort law in effect throughout most of the western world, a party injured by adverse effects from a vaccine can be paid under a legal claim only by proving the manufacturer or its product faulty. If successful, the claimant would be paid not only for his medical expense and wage loss but for his pain and suffering. But proving (a) the defendant's conduct or product faulty and (b) the monetary value of nonmonetary loss (pain and suffering) is usually so complex that many injury victims are paid not at all, or only a fraction of their losses in settlement, only after long delay, and only after lawyers on both sides are paid large amounts of insurance dollars in litigation costs.

Athletic Injuries↗