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Results for “Insurance Claim Reporting”

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At least 37 records · Page 2Linked to original sources
PubMed1996

EDI helps PHOs meet information needs.

While the organizational structures of physician-hospital organizations (PHOs) may differ from region to region, financial management of all PHOs requires that comparable information about the type and volume of patient services provided under each contract must be available so that the profitability of different contracts can be analyzed. However, comparable information often is not readily available. Obtaining these data is a challenge facing all PHOs. One Midwest healthcare system has designed and implemented an inexpensive electronic network that connects most of the participants in its PHO. This network has enabled the PHO to obtain information about the care provided under its contracts, information that would not be available otherwise.

Computer Communication Networks↗
PubMed1998

Payers required to adopt standardized electronic claims processing.

The Health Insurance Portability and Accountability Act of 1996 requires most claims payers to support electronic claims processing and uniform national standards for code sets and identifiers to streamline healthcare administration. The law will penalize payers that do not support the standards and are not prepared to conduct business electronically by the year 2000. Many providers may qualify as claims payers and, thus, will be subject to penalties if they do not adopt EDI for the transactions required by the Act. Providers also will have greater opportunity to eliminate paper, speed claims payments, and cut administrative overhead. Both providers and payers will have new guidelines for privacy and confidentiality, and violation of these guidelines will result in significant penalties. Consequently, all providers should become familiar with the legislation and evaluate their EDI strategy in light of new opportunities and responsibilities.

Chronology as Topic↗
PubMed1998

Real-time claims resolution. Re-engineering how we process and pay for healthcare.

UNLABELLED: A Preferred Provider Organization with about 9,000 providers in three states. PROBLEM: A fragmented and confusing healthcare payment and processing system, which ultimately hurts everyone, the patient, the provider and the payor. SOLUTION: Create a real-time claims resolution system which links everyone for quick payment of the claim at the point of service. RESULTS: Reduces paper and accelerates the claims cycle. KEYS TO SUCCESS: "Re-engineer the current system of processing and paying healthcare claims with a business model that economically benefits all parties."

Evaluation Studies as Topic↗
PubMed1998

Designing an internal audit process for physician billing compliance.

An internal audit process is central to an effective compliance program. When based on pertinent Federal regulatory guidelines and executed by staff with appropriate technical expertise, an internal audit limits opportunities for noncompliant physician billing and reduces the risk of incurring financial penalties. The design of an effective internal audit process will incorporate uniform internal audit procedures, communication mechanisms, and educational initiatives to correct any deficiencies that are identified. For healthcare organizations that are involved with physician group practices, review of physician documentation is particularly important. This review provides essential information on potential areas of risk and offers a focus for future education of physicians regarding appropriate billing and documentation.

Communication↗
PubMed1987

Communications between insurers and providers.

Physicians are frequently distressed by their communication with insurers. This article describes the process insurers utilize to collect data, set reimbursement rates, and utilize peer review.

Communication↗
PubMedDate not supplied

Impact of fraudulent claims on health care costs.

The U.S. health care system, considered one of the best in the world for technological sophistication and availability of services, is being seriously threatened by continually escalating costs. Although there are many reasons for this, fraud within the industry accounts for 10 percent of the nation's annual health care bill. By the end of the decade, the fraud factor may cost the industry $160 billion a year. Health insurers and state and government agencies are joining forces to share information and intensify their efforts in the battle against fraud. MetLife's in-house efforts include a specialized unit devoted entirely to the prevention, detection and prosecution of fraud. In 1990 the company's vigilance saved its policyholders over $38 million.

Data Collection↗
PubMed1991

Differential treatment of occupational disease v occupational injury by workers' compensation in Washington State.

Washington State's workers' compensation claims filed in 1984 and followed through 1988 contained 11,356 claims for occupational disease and 178,927 claims for occupational injury. There was a higher rate of rejection (18% v 4%) and resource utilization (14% v 5%) for occupational disease when compared to occupational injury. The factors most predictive of rejection included the specific disease category and the provider frequency of filing. Development of diagnostic guidelines would aid health providers in identifying and properly characterizing occupational diseases.

Accidents, Occupational↗
PubMed1991

Playing the red tape blues.

Explore the source record for details and available documents.

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