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Results for “Insurance Claim Reporting”

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PubMed1976

Thoughts on the prevention of urologic liability claims.

We have approached the problems of increasing urological liability claims with a superficial study of their causes and some suggested solutions. We believe that this approach is important because it is one that the urological community can take immediately rather than waiting for changes in state and federal laws that may be of benefit in decreasing the impact of these suits. It seems to be the common disease and the simple operation that lead to the lodging of a claim.

Humans↗
PubMed1999

A case study of point-of-service medical use in a managed care plan.

This study examines the extent of point-of-service use in a managed care plan using 1990 and 1991 proprietary claims data (excluding pharmacy claims) from a large, well-established individual practice association with a point-of-service option. Results show that approximately 12 percent of all claims were made by out-of-network providers, representing about 9 percent of the dollar value of all claims. This is about $131 per enrollee per year. While younger enrollees (i.e., 6-24 years of age) use fewer medical resources than do older enrollees, they tend to receive a greater share of their medical services from out-of-network providers. There is little difference between point-of-service use by males and females. Mental illness is the most common diagnosis for out-of-network claims, accounting for about 25 percent of the dollar value of out-of-network claims. Ninety-six percent of the out-of-network claims for this diagnosis category were made by providers with a specialty in psychiatry.

Cost Sharing↗
PubMed1998

The insurance refund request: a legal analysis.

When an insurance payment is made erroneously to a healthcare provider and no contract between the insurer and provider addresses the issue of refunding such payments, the law relating to restitution generally applies. Restitution does not apply, however, to three exceptions that the courts have used to refuse claims by insurers for refunds of overpayments: the innocent third-party creditor exception, whereby the healthcare provider cannot be unjustly enriched by the overpayment, cannot have induced the mistaken payment, and cannot have known beforehand that the insurer was not obligated to pay; the material change in position exception, whereby the healthcare provider in good faith accepts an overpayment and so does not pursue other means of payment; and the assumption of the risk exception, which occurs when the insurer pays a claim without having complete information about it.

Financial Management↗