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Results for “Insurance Claim Reporting”

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At least 19 recordsLinked to original sources
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.↗
PubMed1990

Changing physician behavior: does medical review of Part B Medicare claims make a difference?

This study attempts to determine whether the implementation of mandatory review of Medicare Part B claims for medical necessity has resulted in physicians submitting fewer medically unnecessary claims. After summarizing the literature on the effectiveness of various methods for changing physician practices, we compare the rate at which physicians submitted medically unnecessary claims before and after HCFA imposed mandatory review screens. We find that, consistent with expectations from the literature, the screens are only marginally effective (at best) in reducing the rate at which medically unnecessary claims are submitted. We make some suggestions for lowering this rate.

Cost Control↗
PubMed1979

Survival following renal transplantation in Saskatchewan, 1970--74: follow-up study using medical insurance records.

The patient history file of a medical care insurance plan can be used for statistical purposes in many ways. This is illustrated by the use of the records of the Saskatchewan Medical Care Insurance Commission to study the survival of patients receiving kidney transplants in the period 1970--74. During this period 48 males and 23 females received at least one renal transplant; these patients represented 34% of all males and 28% of all females undergoing regular renal dialysis. These period prevalence estimates are consistent with calculations based on incidence and point prevalence reported elsewhere. Life-table calculations showed the 4-year survival rate following first kidney transplantation in Saskatchewan to be 45% for all patients, 55% for those less than 45 years of age and 26% for those 45 years of age or older.

Actuarial Analysis↗
PubMed1992

Coding and reimbursement of primary care biopsy and destruction procedures.

Current medical practice requires physicians to accurately report services provided to patients. Billing for destruction of benign and malignant lesions and for surgical, needle, and endoscopic biopsy procedures involves the selection of specific 1992 Current Procedural Terminology (CPT) codes. Payment for these procedures by third-party payers often requires the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding for neoplastic lesions. This review explains the proper codes to use in identifying common biopsy and destruction procedures performed by primary care physicians. The Health Care Financing Administration's relative value units and one state's published Medicaid payment rates are included for each procedure code. Instructions for selecting site-specific biopsy and destruction codes are provided.

Abstracting and Indexing↗
PubMed1992

Are radar detector users less safe than nonusers?

One hundred and seventy-four drivers who had purchased special insurance coverage during 1988-1989 for in-vehicle equipment that included a radar detector were compared to a similarly sized and sociodemographically stratified driver population random sample. It was found that the radar detector owners had significantly more accident claims and speeding convictions during the period 1986-1989 than those representing the general driver population.

Accidents, Traffic↗
PubMed1990

Applying insurance claims data to assess quality of care: a compilation of potential indicators.

Insurance claims records, which document many aspects of the process and outcome of medical care, are a practical and unobtrusive source of data for monitoring the quality of care provided to enrollees--a purpose for which they are rarely used. Data for these potential indicators could be drawn from claims or other administrative data systems. The authors established categories of care that could be used to develop claims-based indicators and compiled an annotated list of broad indicators for assessing the quality of care. The compilation of indicators is preceded by a discussion of some of the issues and challenges facing those who use and interpret claims-based indicators of quality.

Data Collection↗
PubMed1990

Universal New York Health Care. A single-payer strategy linking cost control and universal access.

Now that universal access to health care is back on the governmental agenda, elected officials are faced with the dilemma of expanding our present pluralistic system of numerous private and public payers, with its built-in administrative inefficiencies and inflationary pressures, or scrapping the present system of financing and moving to a tax-based scheme like the Canadian Medicare program, an option fraught with political difficulties. There is, however, a third option. The New York State Department of Health has developed a proposal for universal access--Universal New York Health Care, or UNY-Care--that would retain the existing payers, including employer-based insurance coverage, but combine them in a one-payer framework. Providers would no longer have to interact with the many public and private payers, each with its own rules, criteria, and levels of payment. The single payer would serve as the only payer for most health care services and would also negotiate reimbursement rates. The single-payer framework should bring savings in administrative and billing costs and should move government closer to the goal of buying health care services--getting good value for payment rendered--rather than simply paying bills as they are submitted. Although the single-payer strategy could be implemented at either the state or the federal level, it seems ideal as the principal responsibility of the states in a national plan for universal coverage.

Cost Control↗
PubMed1990

Trilogy of the "Triad of O'Donoghue" in the knee and its analogy to the TMJ derangement.

An attempt has been made to describe the similarities between the pathological injury "Triad of O'Donoghue" in the knee and its analogous equivalent in the internal derangements of the temporomandibular joint (internal derangements). Because of the similarities between these internal derangements and the treatment they require, TM joint internal derangements should be reimbursed as a medical problem by insurance carriers as internal derangements in the knee are reimbursed. A description of the anatomical, physiological, and arthro-kinomatics of these two synovial joints has been done to further point out that they both operate by the same physiological principles, and therefore should be treated as similar dysfunctions. Treatment should be rendered to the TM joint, as in the knee, from an orthopedic viewpoint. This requires that treatment to the TM joint include a cooperative rehabilitative team approach. This team approach encompasses medical and dental cooperative care to stabilize the joint and secondarily control joint related soft tissue compensation and pain.

Abstracting and Indexing↗