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PubMed1988

Regulating physician supply: the evolution of British Columbia's Bill 41.

This paper traces the development of British Columbia's controversial Bill 41, which empowers that province's Ministry of Health to restrict the issuance of billing numbers entitling physicians to seek payment from the provincial medical services plan. The bill and its predecessors have been the subjects of two court challenges by the medical profession, and the legal battles continue. The bill has also taken on a role in the evolving interpretation of Canada's new Charter of Rights and Freedoms. Meanwhile, the policy appears to be slowing the rate of growth in physician supply in the province, but its impact on the real target--medical care costs--is still uncertain.

British Columbia↗

PubMed2006

Should providers be allowed to extra bill for uncovered services? Debate, resolution, and sequel in Japan.

Japan has managed to provide universal coverage at relatively low cost by containing prices and restricting the conditions for which services can be billed in the compulsory social health insurance (SHI) program. However, decline in Japan's economic growth ushered in new actors backed by the prime minister who proposed that the providers should be allowed to extra bill for services not covered by the SHI. In 2004 they took the strategy of drawing the attention of the public to areas where the rigidity of the current prohibition appeared to be unfair and ridiculous. They were opposed by the Ministry of Health, Labor, and Welfare and the Japan Medical Association, who strongly objected on the grounds of safety and equity. The compromise reached by the two ministers in charge led to a clarification of the services that are to be covered and of the process for extending coverage to new procedures and drugs. The prohibition on extra billing has remained essentially unchanged, but the momentum for deregulation has been lost. In 2005 an alternate proposal was made to contain SHI expenditures by introducing a global cap on health expenditures and increasing out-of-pocket payment. Although this proposal was not fully adopted, the gradual decline in SHI benefit levels could lead to a renewed move to allow extra billing.

Accounts Payable and Receivable↗

PubMed2003

Adoption of retrospective Medicare maximization billing practices by state Medicaid home care programs.

Home care services funded by Medicare and Medicaid grew rapidly throughout most of the 1990s. During this period some state Medicaid programs transferred costs for home care claims to the Medicare program to reduce their liability and increase beneficiary access to Medicare coverage. This article reports the findings of the first national study of these Medicare maximization billing practices for home care services. Primary data were collected to determine which states conduct retrospective Medicare billing practices and the amounts recovered from Medicare. Our analysis indicates that seven states recovered as much as dollar 265 million from Medicare in state and federal dollars during the 1990s. Ratios of recovered expenditures-to-costs incurred for retrospective billing practices conducted in Connecticut, New York, and Massachusetts are between 5:1 and 7:1. While retrospective billing practices may aid states in reducing Medicaid outlays and potentially help dual Medicare beneficiaries gain coverage for their home care claims, they increase Medicare expenditures for home care at a time of concern for the long-term financial viability of Medicare and illustrate the need for reforming our national long-term care financing policy.

Costs and Cost Analysis↗

PubMed1995

Revenue enhancement through total quality management/continuous quality improvement (TQM/CQI) in outpatient coding and billing.

To survive and thrive, rural hospitals are seeking enhanced revenues. This study focuses on outpatient laboratory and radiology coding and billing accuracy in a nonrandom sample of seven rural hospitals in a Western state. Information was gathered on (1) procedures incorrectly coded, (2) potential revenue increases from correct coding and billing, (3) barriers to implementing changes, and (4) perceived audit value. The identified major source of potential revenue enhancement was increased fees from private payers. Correct coding and billing to Medicare and Medicaid offered the potential of additional revenue. Participating administrators appreciated the validation of coding and billing practices and identification of potential enhanced revenues. Five of seven hospitals (71.4%) selectively implemented recommended changes. Complete compliance with recommended changes was limited by barriers of tradition, competition, and reimbursement, which must be overcome to realize successful implementation. Joint Commission on Accreditation of Healthcare Organization's (JCAHO) new Total Quality Management/Continuous Quality Improvement (TQM/CQI) emphasis provides an opportunity for revenue enhancement through coding/billing assessments and interdepartmental focus and coordination.

American Hospital Association↗

PubMed1995

Drawing the line: issues of boundary and the homosexual law reform bill campaign in New Zealand (Aotearoa), 1985-86.

The 1985-86 Homosexual Law Reform Bill campaign in Aotearoa (New Zealand) was about 'drawing the line' in several important ways. This paper examines issues of boundary as they arise in the way in which the State contains lesbian and gay populations and hence its response to the pro-Bill movement, the struggle of competing groups over the meaning and progress of the Bill, and some of the difficulties of coalition politics. Rituals, symbols and discourses used throughout the campaign by all sides set the scene for the movement of the legislation through Parliament and the eventual outcome. Issues of power, particularly those concerned with gender, ethnicity, and class, crucially influenced the campaign both inside and outside the lesbian and gay movement. Some reasons why the eventual victory for pro-Bill groups was only partial are suggested.

Civil Rights↗

PubMed2005

[The experience in Uruguay: the Bill for the Defense of Reproductive Health].

This article reports on the recent Uruguayan experience with the debate on sexual and reproductive rights. While the Bill for the Defense of Reproductive Health did not pass in the Senate, both the prior process and the subsequent impacts have been relevant, generating a social debate that is still incipient but has involved the mass media, academia, and the political parties and spawning a discussion that has involved both houses of Congress for the first time. Within this context, an outstanding role has been played by NGOs devoted to the defense of women's rights (especially sexual and reproductive), who established a coordinating body that included the trade union movement, which supported the bill. The debate also led to international ties that projected it beyond the country's borders. The article briefly reviews the background and basis for the bill, the research it entailed, and the international commitments assumed by Uruguay, before concluding with a summary of the bill itself and the challenges it poses in terms of sexual and reproductive rights, specifically with regard to voluntary interruption of pregnancy.

Abortion, Illegal↗

PubMed2004

Serum concentrations of ionized calcium, vitamin D3, and parathyroid hormone in captive thick-billed parrots (Rhynchopsitta pachyrhyncha).

Serum collected from 68 thick-billed parrots (Rhynchopsitta pachyrhyncha) from 15 institutions was analyzed for ionized Ca (iCa), total Ca (tCa), P, total protein (TP), albumin (Alb), parathyroid hormone (PTH), and vitamin D3. Values were not distributed normally; 95% frequency intervals were as follows: iCa (0.82-1.3 mmol/L), tCa (1.37-2.09 mmol/L,), P (0.35-1.75 mmol/L), TP (21-39 g/L), Alb (9-13 g/L), PTH (0-65.68 pmol/L), and vitamin D3 (5.2-51 nmol/L). Sixty percent (+/-7.5%) of tCa was ionized. Female thick-billed parrots had significantly higher mean iCa (1.11 mmol/L, n = 22) than male thick-billed parrots (1.05 mmol/L, n = 32). tCa and iCa values in thick-billed parrots were lower than the reported values for other psittacine species. A significant positive linear relationship existed between Alb-TP and iCa-tCa ratios. A significant inverse linear relationship was also identified between the tCa-P ratio and PTH. These findings are consistent with known domestic avian Ca physiology.

Animals↗

PubMed1995

Probable epizootic chlamydiosis in wild California (Larus californicus) and ring-billed (Larus delawarensis) gulls in North Dakota.

During the summer of 1986, more than 400 California gulls (Larus californicus) and ring-billed gulls (Larvus delawarensis), primarily fledglings, died on an island in Lake Sakakawea near New Town, North Dakota (USA). Mortality was attributed largely to chlamydiosis. Necropsy findings in nine carcasses included splenomegaly (n = 9), hepatomegaly (n = 4), and pericarditis (n = 1). Livers from three California gulls and two ring-billed gulls, and spleens from the same five birds plus a third ring-billed gull were positive for Chlamydia psittaci by the direct immunofluorescence test. Chlamydia psittaci was isolated from separate pools of liver and spleen from one California gull and one ring-billed gull. This is believed to be the first record of epizootic chlamydiosis in gulls and the second report of epizootic chlamydial mortality in wild birds in North America.

Animals↗

PubMed1988

Billing delays cause hassles, but hospitals still have to pay for services provided.

A hospital has a contract with the manufacturer to maintain and service copying machines owned by the hospital. The contract calls for the hospital to pay a set minimum monthly fee plus a per-copy charge for all copies made over a set amount. The supplier doesn't furnish any paper products. Recently the hospital received an invoice for 17 months' service. When contacted about this large bill, the supplier told the hospital that it had inadvertently dropped the hospital from its billing computer and had failed to bill the hospital each month. The hospital protested the pressure that this billing practice put upon its budget and asked for an adjustment. The supplier refused to make any adjustment in the amount but did agree to accept the arrears in monthly payments over a year with no interest charges. In this dialogue below, Dr. Decker discusses the legal issues involved in this situation.

Accounting↗

PubMed1988

Summarized patient bill reduces complaints.

Reading traditional itemized bills can be a frustrating experience, raising many questions from patients speaking in raised voices. But nary a harsh word is heard from AMI-Columbia Hospital's billing office since the hospital switched from the often confusing itemized bill to a shorter summary bill.

Accounting↗

PubMed1988

In re the Adoption (Amendment) Bill 1987, 26 July 1988.

The President of Ireland referred to the Supreme Court the question whether Section 3 of the Adoption (Amendment) Bill was repugnant to family rights contained in Articles 41 and 42 of the Constitution. Section 3 authorizes a child of parents who were married to each other to be adopted under exceptional circumstances, i.e., when the parents have totally failed their duty to their child, when that failure arises from "physical and moral" reasons and continues for more than a year prior to application, and when such failure constitutes abandonment. The Court found the Bill constitutional. It held that, under Articles 40.3 and 42.5 of the Constitution, the rights of the child within the family could in extraordinary circumstances be supplied by placing a child in an alternative family, and that the preconditions set forth in the Bill were sufficient to protect the constitutional guarantees afforded to the family. After the Supreme Court reached its decision, this Bill was signed into law as the Adoption (Amendment) Act 1988.

Adolescent↗

PubMed2003

When putting patients first fits the bill.

Cedars-Sinai Medical Center in Los Angeles revamped its billing system to better meet patients' needs for comprehensible billing information. After changing its billing format and processes, the provider's phone-call volume decreased 31 percent, translating into an annual savings of more than $250,000. Patient feedback regarding the new system has been over-whelmingly positive. The new billing system has contributed to 20 percent acceleration in payment.

Efficiency, Organizational↗

PubMed2003

TRIPS from Doha to Cancún ... to Ottawa: global developments in access to treatment and Canada's Bill C-56.

In November 2003, Canada introduced legislation to amend the Patent Act so that manufacturers could obtain licences to make generic versions of patented pharmaceutical products for export to countries lacking sufficient capacity to produce their own. Bill C-56 aims to implement an August 2003 decision of the World Trade Organization (WTO) that relaxes its rules on pharmaceutical patents to allow this kind of measure. While the bill is a welcome development, it contains several serious flaws that will undermine the initiative and render it largely meaningless. Civil society organizations, including the Canadian HIV/AIDS Legal Network, have called on the Canadian government to remedy the flaws before Bill C-56 is enacted. This article provides an overview of recent global developments leading up to Canada's initiative, as well as an analysis of Bill C-56 itself.

Canada↗

PubMed2004

The operative note as billing documentation: a preliminary report.

Certified professional coders from a multispecialty academic surgical practice used operative notes to identify 10 of the most common deficiencies for reimbursement of services. These 10 deficiencies were then used as evaluation criteria to audit the operative notes used as billing documentation. Twenty-four per cent of operative notes contained no deficiencies, whereas the remaining 76 per cent contained one or more audit criteria deficiencies. The three most common deficiencies identified included an incomplete description of all surgical procedures performed (56%), an inadequate description of the indications for procedures (49%), and only 45 per cent of the operative notes were dictated within 24 hours of the procedure. Thirty-nine per cent were dictated by faculty surgeons, whereas 61 per cent were dictated by surgical residents. Twenty-nine per cent of the operative notes that were dictated by faculty surgeons contained no deficiencies as compared with 20 per cent of the operative notes that were dictated by surgical residents. For a multispecialty academic surgical practice, the operative note is the document of justification for 75 per cent of revenue generated. We conclude that 1) the operative note represents the most important document for justification of reimbursement for surgical services, 2) surgeons should reassess the operative note as a billing document and provide the information necessary to expedite reimbursement, 3) surgical residents should be instructed in the details of an operative report as a billing document, and 4) most of the information needed in the operative note for billing purposes is simple and straightforward data that is important not only for reimbursement but also from a medico-legal and medical records standpoint.

Humans↗

PubMed2005

Physician documentation in support of appropriate billing with modifier '-25'.

What is one of the surest ways for a practice to lose revenue and invite the unwanted attention of government auditors? By failing to select and document the appropriate use of modifiers to code for services provided. For example, the Office of Inspector General (OIG) has made it known that they will closely review professional billing with the use of modifier '-25.' The use of this particular modifier appeared on their radar screen, because in one recent year Medicare paid approximately 1.7 billion dollars for Evaluation and Management (E/M) services billed with modifier '-25'. The OIG feels an increase of this amount warrants further investigation to determine if these claims were billed and reimbursed appropriately. Additionally, Oklahoma Medicaid auditors are actively scrutinizing the use of modifier '-25' to a degree even more stringent than Medicare and the CPT code book's description allow. Therefore, it is important that physicians be knowledgeable in determining when it is appropriate to bill using this modifier.

Current Procedural Terminology↗

PubMedDate not supplied

Hospital nursing costs, billing, and reimbursement.

Nursing intensity, estimated direct nursing costs, and daily billing were compared for 12 adult medical or surgical units at an academic medical center from January 1 to May 31, 2005 (22,649 patient days). Two main findings, nursing intensity and direct nursing costs, were highly variable within and across each of the study nursing units (mean 429 dollars, SD 160 dollars); direct costs of nursing care were significantly higher for private room rates compared to intermediate room per diem charges billed at a higher rate (441 dollars vs. 426 dollars, F 37.77, p < 0.001). The results demonstrate that the direct costs of nursing care are not aligned with current billing practices at this university hospital. The use of fixed room and board charges to account for nursing care in U.S. hospitals may be obsolete and an alternative nurse-centric costing, billing, and reimbursement model is proposed.

Academic Medical Centers↗

PubMed1989

71st legislature produces bills that improve health care in Texas.

The 71st Texas Legislature adjourned May 29, ending what was an extremely successful session for the Texas Medical Association. During the 140-day session, TMA tracked more than 600 individual bills and secured passage of major legislation addressing rural health care, Medicaid enhancement, medical liability reform, and other measures to improve the quality of health care and the practice of medicine. TMA also was successful in blocking passage of legislation that might have lowered the quality of care. As this issue of Texas Medicine was going to press, Gov Bill Clements was threatening to veto the rural health care bill, House Bill 18. That issue was a possible agenda item for the special session Clements called for June 20. The special session was called specifically to deal with workers compensation reform, an issue the lawmakers failed to resolve during the regular session. This article, prepared by Ken Ortolon, public relations assistant, and the TMA Public Affairs staff, lists some of the issues TMA was involved in during the 71st session and their outcomes.

Legislation, Medical↗

PubMed2026

Can ChatGPT Replace Human Clinical Coders? A Comparative Study in Otology Billing.

OBJECTIVE: Evaluate the utility of the large language model (LLM), ChatGPT, for the analysis of operative notes and the generation of Current Procedural Terminology (CPT) codes in comparison to human clinical coders. STUDY DESIGN: CPT billing codes assigned by ChatGPT were compared to existing billing data. Otology practice within a tertiary academic center. METHODS: About 191 operative notes from a single surgeon (9/2022-10/2023) were analyzed. ChatGPT-3.5 and 4 models were prompted for CPT codes based on operative notes. Assessment included determining exact and partial match rates, sensitivity and specificity for targeted procedures, and work Relative Value Units (wRVU) differences between ChatGPT-generated and human-assigned codes. RESULTS: ChatGPT-3.5 achieved exact matches in 22% of cases and partial matches in 32%, while ChatGPT-4 achieved 14% exact and 33% partial matches. When cochlear implantation (CI) was excluded, performance dropped significantly. For CI, ChatGPT-3.5 demonstrated a sensitivity of 94% and specificity of 90%, while ChatGPT-4 showed a sensitivity of 96% and specificity of 92%. In contrast, performance on cartilage grafting was poor, with sensitivities of 4.2% for ChatGPT-3.5 and 0% for ChatGPT-4. ChatGPT-3.5 and 4 showed moderate CPT code matching accuracy among themselves, with slight agreement to human coders. Both models tended to underbill for wRVUs compared to human coders, with significant differences in the values generated. CONCLUSION: This study assessed ChatGPT's effectiveness in automating CPT code assignment for otologic surgeries. While the models achieved high sensitivity values for assigning codes related to cochlear implantation, both models struggled with complex cases, failed to apply modifiers, and often assigned fewer wRVUs. The findings highlight ChatGPT's potential in medical billing but indicate a need for further refinement.

Humans↗