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At least 19 recordsLinked to original sources
PubMed2006

Getting your game on with business data.

Data warehouses can virtually eliminate claims-related paper and fax transactions for hospitals. Data are accessible electronically, decreasing the need for staff to check on outstanding claims status requests by phone. Data warehouse technology can be used to create analytical reports and identify issues by dollar volume or procedure code. Providers can receive instant reports on both the "front end," as they are submitted, and on the "back end," when claims are denied.

Database Management Systems↗
PubMedDate not supplied

Disease coding errors by health care organizations: effects of a government quality intervention.

Disease coding errors in claims data can cause serious problems for financing, reimbursement systems, public health surveillance and health research. This study analysed a government intervention to improve coding accuracy of health care organizations in South Korea. The intervention was implemented in 1997 by 226 organizations that had submitted erroneous claims in 1996 for five selected diseases. In 1998, 94% of these organizations eliminated coding errors for these diseases. Those organizations least responsive to the intervention were tertiary hospitals, those publicly owned, and those with other complex organizational characteristics. Overall, this simple intervention appeared extremely effective, and wider adoption of such techniques should be explored.

Communicable Diseases↗
PubMed1991

Structure, process, effectiveness and efficiency of the check and review system in Japan's health insurance.

Keeping medical costs at an adequate and affordable level cannot be realized by the efforts of medical facilities alone, nor by the revision of fee schedules and price schedules of drugs in Japan's health insurance systems. Rationalization and improvement in the efficiency of all of the systems, including the various insurance organizations and the organizations for review and payment, are imperative. This paper first examines the system of review and payment for insurance claims under Japan's health insurance systems with emphasis on three main points, namely (1) qualification checks, (2) check and review of insurance claims and (3) computerization of the screening process. Relevant issues facing the check and review system are then discussed.

Cost Control↗
PubMed2006

The accuracy of Minimum Data Set diagnoses in describing recent hospitalization at acute care facilities.

OBJECTIVES: The Minimum Data Set (MDS) is the resident assessment instrument used to guide clinical care, reimbursement, and assess quality in long-term care facilities. This database has been used in many studies, although the accuracy of many data elements remains unknown. This study evaluated the accuracy of the MDS diagnosis variables with respect to the diagnoses for recent hospitalization from Medicare claims data. DESIGN: Retrospective cohort study. SETTING: 945 skilled nursing facilities in Ohio. PARTICIPANTS: 17,294 residents admitted from an acute care facility during 2000. MEASUREMENTS: Eleven diagnoses listed in the MDS were compared with Medicare hospital discharge claims. Specifically, each MDS diagnosis was compared to the primary diagnosis, the list of secondary diagnoses, and the Diagnosis Related Group (DRG). RESULTS: Claims diagnoses were listed in the MDS with an average frequency of 79% (range: 31%-94%) for the primary diagnosis, 66% (range: 33%-90%) for any diagnosis, and 71% (range: 31%-94%) for the DRG. MDS diagnoses were listed as the primary diagnosis, any diagnosis, and DRG with an average frequency of 20% (range: 6%-81%), 62% (range: 41%-86%), and 19% (range: 7%-84%), respectively, with only hip fracture listed more than 80% of the time. CONCLUSION: The sensitivity of the MDS for listing diagnoses from recent hospitalization appears good for most diagnoses. However, except for hip fracture, the MDS has poor predictive value with regard to the primary reason for the preceding hospitalization; this may have implications for resident care planning and the utility of this database in long-term care research.

Activities of Daily Living↗
PubMed2000

Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury.

BACKGROUND AND METHODS: The incidence and prognosis of whiplash injury from motor vehicle collisions may be related to eligibility for compensation for pain and suffering. On January 1, 1995, the tort-compensation system for traffic injuries, which included payments for pain and suffering, in Saskatchewan, Canada, was changed to a no-fault system, which did not include such payments. To determine whether this change was associated with a decrease in claims and improved recovery after whiplash injury, we studied a population-based cohort of persons who filed insurance claims for traffic injuries between July 1, 1994, and December 31, 1995. RESULTS: Of 9006 potentially eligible claimants, 7462 (83 percent) met our criteria for whiplash injury. The six-month cumulative incidence of claims was 417 per 100,000 persons in the last six months of the tort system, as compared with 302 and 296 per 100,000, respectively, in the first and second six-month periods of the no-fault system. The incidence of claims was higher for women than for men in each period; the incidence decreased by 43 percent for men and by 15 percent for women between the tort period and the two no-fault periods combined. The median time from the date of injury to the closure of a claim decreased from 433 days (95 percent confidence interval, 409 to 457) to 194 days (95 percent confidence interval, 182 to 206) and 203 days (95 percent confidence interval, 193 to 213), respectively. The intensity of neck pain, the level of physical functioning, and the presence or absence of depressive symptoms were strongly associated with the time to claim closure in both systems. CONCLUSIONS: The elimination of compensation for pain and suffering is associated with a decreased incidence and improved prognosis of whiplash injury.

Accidents, Traffic↗
PubMed2000

Results of provider self-adjudication using the prudent layperson standard compared with the managed care organization's emergency department claim review process.

STUDY OBJECTIVES: We compare the results of a provider "self-adjudicating" outpatient emergency department claims using a "presenting symptom-based" system with the managed care organization (MCO) adjudicating the claims using a "final diagnosis-based" system. METHODS: All outpatient visits from one MCO to an urban, university hospital between January 1, 1998, and February 28, 1999, were included. Each record was reviewed by 2 methods to determine whether the visit qualified for payment under the MCO's benefit structure. Under the provider adjudication, symptom-based system, all visits with nursing triage levels of immediate/emergency were approved automatically. Those with triage levels of delayed/nonurgent were reviewed by an emergency physician and approved if, in the physician's opinion, the presenting symptoms met the emergency criteria under the District of Columbia's Access to Emergency Services Act. A second claims review, blinded to the first, was performed with the diagnosis-based system used by the MCO before approval of the prudent layperson standard. This review divided the records into "approve," "deny," and "suspend" categories according to the discharge International Classification of Diseases, ninth revision code. The results of the 2 reviews were compared. RESULTS: We reviewed 1,830 records; 836 (46%) cases were triaged as immediate/emergency and 994 (54%) as delayed/nonurgent. Of the 994 delayed/nonurgent visits, physician review determined that 607 (61%) met the prudent layperson standard and 387 (39%) did not. Overall, the provider self-adjudication system determined that 1,443 (78.8%) of the 1,830 visits should be approved for insurance coverage. The MCO's system approved 966 (53%), denied 335 (18%), and suspended 529 (29%). Provider self-adjudication using a symptom-based system resulted in the immediate approval of 1,443 (77.8%) visits compared with 966 (52.7%) by a diagnosis-based system (P <.001). Excluding the 529 suspended claims, McNemar's statistical testing of 1,302 records failed to demonstrate the equivalence of the 2 systems (P <. 001). CONCLUSION: Compared with the standard ED claims review process used by the managed care industry, provider self-adjudication using a symptom-based system approves a greater proportion of visits, avoids rejection of many ED visits, and identifies many nonemergency visits that mistakenly appear to be emergencies. The possibility of providers and MCOs working together to adjudicate outpatient ED claims should be explored.

Ambulatory Care↗
PubMed1994

Analysis of automated administrative and survey databases to study patterns and outcomes of care.

Large computerized databases often arise from national surveys, insurance claims, and statewide health care registries. These databases are increasingly used to examine patterns of medical care and certain outcomes of care and may be helpful in planning clinical trials. They are highly representative of defined populations, but have limited clinical information. Methods have been developed to identify episodes of low back pain and to quantify the severity of unrelated, comorbid medical conditions. Pitfalls in analysis are discussed, including limitations of diagnosis and procedure coding, cross-sectional nature of most data, limited clinical detail, and the necessarily observational (not experimental) nature of any group comparisons. There is growing interest in expanding the clinical information in such databases, for both quality improvement and research purposes.

Cross-Sectional Studies↗
PubMed1997

The financial impact of changes in personal health practices.

The impact of changes in health practices on medical claims costs between 1985-1987 and 1988-1990 was examined among 796 employees. Employees completed a health risk appraisal in 1985 and 1988 and were categorized into health risk levels. High-cost status and high-risk status were significantly associated at both times. The percentage of employees with high-risk status decreased from 31.8% to 25.3% between 1985 and 1988 (P < 0.01). Changes in average costs and the percentage with high-cost status followed the risk change. The largest increase in average costs occurred in employees who moved from low-risk to high-risk status. The greatest reduction in average costs occurred in employees who moved from high-risk to low-risk status. Median costs were not as sensitive to risk change. The findings provide strong evidence that improving individual health status is associated with financial benefits.

Absenteeism↗
PubMed1995

Developing a quality improvement database using health insurance data: a guided tour with application to Medicare's National Claims History file.

Health policy researchers are increasingly turning to insurance claims to provide timely information on cost, utilization, and quality trends in health care markets. This research offers an in-depth description of how to systematically transform raw inpatient and ambulatory claims data into useful information for health care management and research using the Health Care Financing Administration's National Claims History file as an example. The topics covered include: (a) understanding the contents and architecture of claims data, (b) creating analytic files from raw claims, (c) technical innovations for health policy studies, (d) assessing data accuracy, (d) the costs of using claims data, and (e) ensuring confidentiality. In summary, claims data are found to have great potential for quality of care analysis. As in any analysis, careful development of a database is required for scientific research. The methods outlined in this study offer health data novices as well as experienced analysts a series of strategies to maximize the value of claims data for health policy analysis.

Aged↗