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At least 19 recordsLinked to original sources
PubMed1975

[Unusual self mutilation with the purpose of obtaining illegal insurance benefits].

In this unusual form of self mutilation the fracture of the phalanx has been carried out--upon request--by foreign person (inderect self mutilation), in order to obtain illegal accident insurance money. Short survey of the relevant literature is given and the possibilities are outlined, which facilitate at the primary wound dressing the establishment of suspicious cases.

Absenteeism↗
PubMed1979

The use of medical records by adjudicators in processing Social Security disability insurance benefit claims.

The Social Security Administration contracts with state agencies to process disability claims filed under the Social Security Act. These state agencies employ physicians and lay adjudicators who secure medical reports from physicians, hospitals and clinics, and use these reports in awarding or denying disability benefits. This nationwide study showed that well over half of the lay adjudicators are involved in developing and interpreting medical information independently. This suggests that appropriate hiring practices, adequate training and certification procedures should be instituted to ensure that the lay disability adjudicators are able to conduct their job efficiently and correctly.

Disability Evaluation↗
PubMed1978

[Recognition of a skin disease as an occupational disease according to the current legislation].

Admission of the insurance qualifying occupational skin disease (No. 5101 of Schedule 1 of the Occupational Disease Regulations = BeKV) has as its pre-requisite the availability of the medical evidence. The beginning of the period qualifying for insurance benefit shall be determined retrospectively. A hazardous activity appertains even if only a minor portion of the field of activity is the cause of the disease. Qualifying for insurance benefits requires that this activity shall have been finally given up and that the same or other hazardous activities are avoided in the future. This prognosis must have a good measure of probability. Otherwise, if the insured acts in bad faith, a pension may be withheld; if the insured acted in good faith a worsening of a syndrome by the hazardous activity (whether carried on as occupation or on one's own behalf) is not compensated for. The insurance qualifying date, furthermore, is dependent on the necessity for first-time medical treatment, medicines or therapeutic agents, or the incapacity for work, or the arising of a pension-qualifying reduction in earning power.

Dermatitis, Occupational↗
PubMed1978

The psychiatrist and health insurance claims review.

Expanded health insurance benefits for the treatment of mental illness have obliged psychiatrists to devote more time to justifying psychiatric treatment to claims reviewers. The author, drawing from experience in utilization review and peer review, summarizes factors contributing to the denial of payment for psychiatric services by health insurers, and gives practical advice on protecting against claims denials and on the process of appealing denials. Psychiatrists should make greater use of peer review committees to justify legitimate treatment services in the face of claims denials. Greater coverage for psychiatric treatment under national health insurance will increase the psychiatrist's responsibility for public accountability. This accountability will require better communication between psychiatrists and claims reviewers.

Insurance Benefits↗
PubMed1977

Private industry health insurance plans: type of administration and insurer in 1974.

This report examines the major forms of administration of private health insurance plans. Plans are classified according to whether they are employer-only or joint worker-employer-operated and according to whether they are negotiated or not. A further focus of examination that often reflects industry patterns is whether the plans cover workers of a single employer or involve multi-employer arrangements. These classifications of administration and the method of insuring benefits are examined in terms of proportions of workers with specified plan characteristics and health benefits.

Blue Cross Blue Shield Insurance Plans↗
PubMed1978

Considerations in the design of mental health benefits under National Health Insurance.

The existing insurance coverage for mental health benefits provides incentives for hospital as compared with community care and reinforces a medical approach to psychological disability. Moreover, the structure of benefits favors the affluent as compared with the disadvantaged and provides little assistance for the community integration of the chronic mental patient. In considering mental health benefits under National Health Insurance we must be careful to avoid reinforcing these patterns. It is suggested that NHI include a mental health resource development fund intended for building a stronger network of community mental health care and that the pattern of insurance benefits under NHI be consistent with developing psychiatric services on a capitation basis.

Community Mental Health Services↗
PubMed1992

Judicial and legislative responses to cost containment.

Cost containment through reduction of insurance benefits and aggressive utilization review is increasingly risking the sacrifice of good clinical care in the pursuit of financial objectives. This article provides examples of judicial and legislative responses to perceived fiscal intrusions into clinical practice. Principles for asserting clinical goals in the cost containment process are also provided to assist in the inevitable negotiations and battles ahead.

Adult↗
PubMed1977

Private industry health insurance plans: employment requirements for coverage in 1974.

In 1974, approximately 28.4 million active workers participating in almost 52,000 health plans on their jobs were covered by in-hospital health insurance benefits. A survey of these plans, conducted for the Social Security Administration by the Bureau of Labor Statistics, revealed that not all workers are automatically entitled to benefits on the first day they report for work. More than three-fifths had to fulfill at least one job-related requirement before their hospital coverage was effective. The extent and variety of employment requirements in private industry are discussed here along with data that show how plans that have such requirements differ from those that do not.

Collective Bargaining↗
PubMed1992

Legislative interventions to increase access to screening mammography.

Although numerous studies have established that breast cancer mortality can be significantly reduced through early detection, only a small percentage of women obtain screening mammograms at intervals recommended by the National Cancer Institute, the American Cancer Society, and other major medical organizations. This paper examines the importance of cost as a barrier to routine screening and the state legislative movement to make screening mammography a basic health insurance benefit. Mammography "knowledge, attitudes, and behavior" studies offer conflicting findings on the extent to which cost enters into the decision to have a mammogram. Women seldom report cost as a major reason for postponing or failing to have a mammogram; yet, descriptive studies show a consistently positive relationship between income and mammography use. State mammography reimbursement laws vary greatly with respect to whether screening mammography is a required or optional benefit, payment limits, and eligibility and referral requirements. Although state-specific data on the percentage of women with private health insurance are not available, 1987 National Medical Expenditure Survey estimates for U.S. Census geographic divisions suggest that the New England, East North Central, West North Central, Middle Atlantic, and Mountain states have the highest percentages of women who are privately-insured and, thus, potentially eligible for legislated mammography benefits. Access to screening mammography also is likely to be influenced by the proportion of employer-sponsored health plans that are self-insured and, therefore, exempt from minimum benefit mandates and the extent to which women are aware of the screening coverage.

Adult↗
PubMed1976

Issues in national health insurance.

Health insurance, by reducing net price to the consumer and increasing the opportunities for revenue to the provider, has profound effects, among other things, on the volume, content and distribution of services, their prices, and the capacity of providers to produce them. The magnitude and nature of these effects depend, partly, on the design of insurance benefits and, partly, on the nature of the health care system, particularly its current and potential capacity and the methods it uses to pay providers. Those who believe that the unique aim of insurance is to protect against unpredictable expenses attempt to suppress these effects, mainly by imposing financial disincentives to utilization which, in turn, reduce protection for those who need it most. Those who wish to reform the system have a broader range of objectives which include protective efficacy, cost control, quantitative adequacy, qualitative adequacy, efficiency of production, efficiency of allocation, equity, and redistribution of capacity. An analysis of the effects of insurance in the light of these objectives reveals favorable as well as unfavorable consequences. The provision of comprehensive benefits generates the necessity for a fundamental change in the organization of health services, if the advantages are to be fully realized and the disadvantages minimized.

Deductibles and Coinsurance↗
PubMed1975

Equity in paying for health care services under a national insurance system.

The debate over the future of the health care delivery system evolves around the policy issue of what constitutes a fair distribution of the medical services which are considered essential to prolonging life, curing disease, and relieving pain. A case can be made that a socially equitable distribution implies that consumption of medical services is independent of the consumer's income and payment for them unrelated to utilization. The present paper examines to what extent the provisions for financing a national health insurance system are likely to advance or hinder the fair distribution of health care services. Almost all bills specify a mix of direct (cost-shared) and indirect (prepaid) financing. When cost-sharing is based on the quantity of services or on the level of medical expenditure, it helps divert medical care and health insurance benefits to high-income persons at the expense of their low-or moderate-income counterparts. When indirect payments or premium levels are determined by insurance risks rather than by income, they may be too high for persons with moderate means, and are likely to exclude such persons from the national insurance program. When health insurance is tied to salaried employment, it discriminates against the unemployed and the self-employed. To rectify such inequities, some NHI proposals specify separate insurance plans for the disadvantaged. Such programs, which require income-testing to determine eligibility, are likely to be plagued by administrative complications currently engulfing other means-tested social welfare programs. The present paper makes some recommendations for the purpose of avoiding these difficulties and fostering equity in health care.

Deductibles and Coinsurance↗