Medicare--part B. Peer review & medicare.
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Humans↗
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Accuracy of coding in Medicare part B claims. Cataract as a case study.
We studied the accuracy of Medicare part B coding for cataract extraction to provide validation for research involving Medicare data. Hospital and physician office records associated with a sample of 802 paid claims for cataract surgery were reviewed. The sample was randomly selected from 118,420 Medicare part B claims for cataract surgery submitted by physicians in an 11-state sample during the first quarter of 1988. Medical records were successfully obtained for 796 cataract surgery episodes (99.2%), of which 794 (99.7%) indicated that cataract extraction had been performed. In the remaining two cases, cataract surgery was attempted but aborted. In 24 (3%) of the 794 cases, the surgical approach (intracapsular or extracapsular) indicated in the operative note differed from the coded on the physician's bill. In all cases in which the operative note indicated a secondary procedure performed at the time of surgery, the billing information was in agreement. We conclude that, at least in the case of cataract surgery, the Medicare part B database is 99% accurate (95% confidence interval, +/- 0.6%) for cataract surgery having occurred and 96% accurate (95% confidence interval, +/- 1.4%) in terms of surgical approach.
Cataract Extraction↗
Trends in Medicare Part B mental health utilization and expenditures: 1987-92.
This article examines the impact of expanding Medicare Part B coverage of mental health services, based on analysis of 6 years of Medicare Part B claims data (1987-92). Inflation-adjusted per capita spending more than doubled (from $9.91 to $21.63) following the elimination of the annual outpatient treatment limit and extension of direct reimbursement to clinical psychologists and social workers. There was a 73-percent increase in the user rate (from 23.25 to 40.20 per 1,000 Medicare beneficiaries), and a 27-percent increase in the average number of services per user (from 8.9 to 11.3). Mental health spending increased from 1 percent to 2 percent of expenditures for Part B professional services. Ongoing monitoring of mental health utilization is desirable to ensure that recent access gains are not eroded with the increasing shift to managed care and implementation of gatekeeper mechanisms.
Ambulatory Care↗
Medicaid program; state allotments for payment of Medicare Part B premiums for qualifying individuals: federal fiscal year 1998--HCFA. Notice with comment period.
Section 4732 of the Balanced Budget Act of 1997 (Public Law 105-33) amended the Social Security Act to provide for two additional eligibility groups of low-income Medicare beneficiaries for whom Medicaid payment can be made for Medicare Part B premiums during the period beginning January 1998 and ending December 2002. This notice announces the Federal fiscal year 1998 State allotments that are available to pay Medicare Part B premiums for these two new eligibility groups and describes the methodology used to determine each State's allotment.
Centers for Medicare and Medicaid Services, U.S.↗
Estimating the effect of new technology on Medicare Part B expenditure and volume growth: do related procedures matter?
The new Medicare Part B physician reimbursement system requires the Health Care Financing Administration to consider how medical technology contributes to growth in service volume. One estimate of this effect has been made by the Physician Payment Review Commission (PPRC), which estimated how individual new technologies have influenced volume growth. This paper extends the PPRC analysis to include both new technology services and those services that are complementary, or related to, the new technology services. The results show that adjusting for related procedures can increase the estimated cost of new technology by as much as 50 percent. In addition, related procedures can increase the estimated share of volume growth attributable to new technology by as much as 42 percent. This implies that both new and related procedures should be used when implementing physician payment reforms.
Diagnostic Imaging↗
Agreement between physicians' office records and Medicare Part B claims data.
This article tests agreement between demographic, diagnostic, and procedural information from primary-care physicians' office records and Medicare Part B claims for Maryland Medicare beneficiaries. The extent of agreement depended on the category of information being compared. Demographics matched poorly, probably due to incomplete record samples. Important diagnoses were often missing from the medical record. When claims indicated presence of disease, the patient was likely to have the disease, but claims did not capture all people who have the disease. Additionally, many laboratory tests and procedures were missing from the primary-care record. The appropriate use of either of these data sources depends on the specific research question that is being asked.
Demography↗
Medicare Part B spending.
In its continuing effort to identify and examine the trends in Medicare spending for surgical services, the College obtained copies of the Medicare procedure code files for the years 1986 through 1989. The results from analysis of these data files were presented in a report entitled Trends in Medicare Part B Spending 1986-1989, issued by the College in September 1991. This article describes the federal activity that prompted the College to commission the report, and presents some of the significant results of the analysis.
Data Interpretation, Statistical↗
Sensitivity and positive predictive value of Medicare Part B physician claims for rheumatologic diagnoses and procedures.
OBJECTIVE: To examine the sensitivity and positive predictive value of Medicare physician claims for select rheumatic conditions managed in rheumatology specialty practices. METHODS: Eight rheumatologists in 3 states abstracted 378 patient office records to obtain information on diagnosis and office procedures. The Medicare Part B physician claims for these patient visits were obtained from the Health Care Financing Administration. The sensitivity of the claims data for a specific diagnosis was calculated as the proportion of all patients whose office records for a particular visit documented that diagnosis and who also had physician claims for that visit which identified that diagnosis. The positive predictive value was evaluated in a separate sample of 331 patient visits identified in Medicare physician claims. The positive predictive value of the claims data for a specific diagnosis was calculated as the proportion of patients with that diagnosis coded in the claims for a particular visit who also had the diagnosis documented in the medical record for that visit. RESULTS: Ninety percent of abstracted office medical records were matched successfully with Medicare physician claims. The sensitivity of the Medicare physician claims was 0.90 (95% confidence interval [CI] 0.85-0.95) for rheumatoid arthritis (RA), 0.85 (95% CI 0.73-0.97) for systemic lupus erythematosus (SLE), and 0.85 (95% CI 0.78-1.0) for aspiration or injection procedures. The sensitivity for osteoarthritis (OA) of the hip or knee was < or = 0.50 if 5-digit codes specifying anatomic site were required. The sensitivity for fibromyalgia (FM) was 0.48 (95% CI 0.28-0.68). The positive predictive values were at least 0.90 for RA, SLE, and aspiration or injection procedures. Positive predictive values for FM and the 5-digit site-specific codes for OA of the knee were 0.83 (95% CI 0.66-1.0) and 0.88 (95% CI 0.75-1.0), respectively, while the positive predictive value of the 5-digit site-specific codes for OA of the hip was zero (95% CI 0-0.26). The positive predictive value of OA at any site was 0.83 (95% CI 0.76-0.90). CONCLUSION: In specialty practice, Medicare physician claims had high sensitivity and positive predictive value for RA, SLE, OA without specification of anatomic site, and injection or aspiration procedures. The claims had lower sensitivity and predictive value for FM and for OA of the hip. The accuracy of Medicare physician claims for other conditions and in the primary care setting requires further investigation.
Aged↗
Medicare and Medicaid programs; collection of overdue Medicare Part B premiums--HCFA. Notice.
This notice sets forth our policy on collection of Medicare Part B premiums from States with "buy-in" agreements. It describes the assessment of interest on overdue premiums and the offset against Federal financial participation (FFP) if we do not receive payment by the specified date. The intent of this policy is to encourage timely payment of Part B premiums by States.
Centers for Medicare and Medicaid Services, U.S.↗
Medicare program; application of inherent reasonableness to all Medicare Part B services (other than physician services)--HCFA. Interim final rule with comment period.
This interim final rule implements section 4316 of the Balanced Budget Act of 1997. It revises the process for establishing a realistic and equitable payment amount for all Medicare Part B services (other than physician services) when the existing payment amounts are inherently unreasonable because they are either grossly excessive or deficient. This rule describes the factors HCFA (or its carrier) will consider and the procedures it will follow in establishing realistic and equitable payment amounts.
Aged↗
Legal rounds: Decisions of the Supreme Court affecting Medicare Part B claims.
In this article, the author focuses on two recent decisions of the Supreme Court affecting Medicare Part B claims. These decisions are of importance to patients covered by Part B and to parties taking assignments from such patients, including pathologists and other physicians.
Insurance, Health, Reimbursement↗
HCFA publishes final rules for reimbursing clinical social work under Medicare Part B.
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Centers for Medicare and Medicaid Services, U.S.↗
Medicare update: SMS summarizes proposed 1996 changes to Medicare Part B.
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Centers for Medicare and Medicaid Services, U.S.↗
A + B = solution? Merging two Medicare parts might help future solvency.
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Bankruptcy↗
Carrier discretionary practices and physician payment under Medicare Part B: a preliminary report.
Although Medicare is a national program, administration of Part B payments to physicians is in the hands of insurance organizations in ten Medicare regions. The carriers follow varying practices in using actual charges within localities as the basis for determining reasonable charges for physicians' services. While some of these practices have already been shown to influence fee levels, reasonable charge determination involves many more whose influence has not been systematically studied. This paper reviews preliminary findings from a study which examines carrier differences in discretionary practices as to specialties, localities and other claims data that may be merged or compared with Medicare data in determining customary and prevailing prices used to set limits on Medicare payments, and other practices reported in an official questionnaire to carriers. The effect on fee levels and other measures of program performance is being studied after taking into account social, economic and health resource variables extracted from the Area Resource File, that are expected to influence local medical prices through the demand for and supply of physicians' services. Dependent variables representing fees are the 50th percentile of the distribution of weighted customary charges of individual physicians in an area and Supplementary Medical Insurance expenditure per enrollee. The preliminary findings in this paper concern discretionary practices, socioeconomic variables and fee distributions.
Decision Making↗
The impact of the 1997 Balanced Budget Act on Medicare, Part II.
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Budgets↗
The effectiveness of Medicare Part B medical review: issues and alternatives.
The part B medical review methods currently used by Medicare carriers to control resource use suffer from a series of problems including failure to reward deterrence of unnecessary claims, failure to detect substitution of nonreviewed claims, reliance on average rather than marginal measures of performance, excessive focusing of reviews, and the inability to measure effectiveness separately from the intervention. This article describes these problems and proposes a series of alternative strategies for review that may improve these problems.
Cost-Benefit Analysis↗
Medicare Part B: rising assignment rates, rising costs.
In this paper I examine the access, quality, and cost trade-offs of assignment under Part B of the Medicare program for both participating and nonparticipating practices, and discuss the impact of assignment on both physician and patient choices. I also discuss the assignment options, or variants of assignment, that have been pursued and that might be considered for future implementation to curb increases in physician costs. Although one frequently suggested alternative--mandatory assignment--would reduce much of the uncertainty surrounding physician costs and reduce some of the out-of-pocket costs of the elderly, it could promote a two-tier system of care by reducing quality for Medicare beneficiaries, and may produce increases in government expenditures.
Costs and Cost Analysis↗