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At least 19 recordsLinked to original sources
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↗
PubMed1992

New methods for evaluating utilization management programs.

Blue Cross and Blue Shield of Massachusetts, Inc (BCBS), has developed two new methods for measuring the effect of utilization management (UM) in reducing unnecessary hospital use. The "program component" method measures the separate effect of preadmission review, concurrent review, and discharge planning. The "savable days" method produces a composite measure of the effectiveness of the program as a whole. The use of these two methods is illustrated with five years of utilization review data from the BCBS nongroup insurance product. The results can be used by operations managers and policymakers to measure the performance of individual UM components and the program as a whole, to establish goals and monitor program performance, to modify the program in response to changing utilization patterns, to assist in developing premiums, to establish risk-sharing agreements with employers or providers, and to demonstrate the effectiveness of the program for use in marketing.

Blue Cross Blue Shield Insurance Plans↗
PubMed1991

[Complications of local and regional anesthesia. An analysis of closed files of insurance companies].

We report a review of closed insurance claims for local and regional anaesthesia mishaps in the main private professional insurance companies. Twenty eight cases with extensive written documentation were discovered, spanning a 6 years interval between 1983 and 1989, involving 21 epidural, 6 spinal and 1 caudal anaesthesias, half with surgical and half obstetrical indication, and excluding all other blocks. Twenty four out of the 28 patients were relatively healthy. ASA I or II, only 4 ASA III. They fitted 4 items of our taxonomy of known complications: 15 cardiac arrests, 10 neurological damages, 1 systemic toxic reaction to local anaesthetic drug and 1 allergic reaction to dextran. The cardiac arrests resulted primarily from the 3 following or contributing factors: hypovolemia (in 3 cases), added sedation (7) and high or total spinal block following reinforcing doses (8). Twenty two had a poor outcome: 8 deaths, 7 severe neurological injuries, a baby was dead and another child had severe neurobehavioral sequellae. The author points out the limitation of this study--a biased sample of all adverse events and inability to derive an incidence. However some of these events reveal patterns of anaesthetic management which lead to poor outcomes.

Adult↗
PubMed1991

Effect of hospital utilization review on medical expenditures in selected diagnostic areas: an exploratory study.

Quarterly claims data on 43 insured groups were analyzed through multivariate techniques to explore whether the effects of hospital inpatient utilization review vary across selected broad diagnostic areas. Findings suggest that utilization review was associated with decreases in expenditures of approximately 15 percent for diagnoses within the surgical area, a lesser decrease within the mental health area, and still lesser decrease within the medical area. However, these measurements are imprecise both because of the small numbers and the aggregated diagnoses in each category.

Adult↗
PubMed1990

Reducing hospital use and expenditures through utilization review. Findings from an outcome evaluation.

Utilization review (UR) has become a prominent approach to cost containment now used by almost 65% of private group insurance plans. Although insurers have increasingly relied on UR to contain health care costs, until recently little was known about the effects of this cost containment approach. This article reviews some of the key findings of a UR evaluation, based on analysis of claims data on 223 insured groups for the years 1984 through 1986. The evaluation found that UR reduced admissions by 12%, inpatient expenditures by 8%, and total expenditures by 6%. It was estimated that UR generated net savings of $115 per employee per year. Groups adopting UR with high baseline rates of hospital use had larger expenditure reductions and greater net savings. It appears that UR can play an important role in private cost containment and help improve medical care resource consumption.

Cost Control↗
PubMed1990

Proposed criteria for independent peer reviewers.

Because of the complexity of craniomandibular claims, it is difficult for insurance adjusters to keep up with all of the advances and techniques regarding craniomandibular disorders. Insurance companies have found that they can process claims more quickly and economize by having claims reviewed. Because of this, independent insurance reviews have become routine for TMJ claims. Many practitioners contend that the current review system appears to be lacking in impartiality, criteria for reviewers, and standardized fees for various geographical locations. The author offers suggestions for objective reviews that ensure the use of qualified and responsible reviewers. Setting guidelines for reviewers will bring about more equitable reviews and assist in dismantling the confusion surrounding head and neck claims.

Humans↗
PubMed1989

In-depth analysis of anesthetic mishaps: tools and techniques.

In-depth analysis of an anesthetic mishap requires the acquisition and analysis of a complex body of data. These tasks are facilitated by specific tools and approaches. At the outset, the reviewer should create a registry for documents and seek a factual overview of events. Basic information about case management should be obtained with a structured survey instrument. Critical pieces of information must be explicitly indexed for later examination. Timelines are particularly effective for organizing and displaying key events. The process of data analysis can be expedited by starting with broad concerns and moving to finer distinctions in a stepwise manner. Preparation of a short summary is the first analytic task. Next, the relationships between the injury, the mechanism of injury, and the contributory actions of the caretakers are formally linked as a hypothesis of injury. Finally, each contributory action is examined individually to determine if it represents a deviation from the standard of care. Contradictory information is an expected feature of in-depth analysis. This problem can often be resolved by testing for clinical relevance, identifying obvious inaccuracies, and emphasizing findings from the most reliable sources. Recent work suggests that practicing anesthesiologists can analyze mishaps with a significant degree of interrater reliability. Thus, aggregate data obtained from in-depth analysis may play an increasingly important role in research, risk management, and peer review.

Anesthesiology↗
PubMed1992

The effects of utilization review on hospital use and expenditures: a covariance analysis.

Hospital utilization review (UR) has expanded rapidly in recent years and is now widely used by private payers as an approach to cost containment. This article reports estimates of the effects of UR on hospital utilization and medical expenditures based on a covariance estimation procedure. Claims data on 223 privately insured groups were analyzed covering a three-year period, 1984 through 1986. UR was associated with an approximate 12 percent decrease in admissions, a 14 percent decrease in hospital routine expenditures, and a 6 percent decrease in total medical expenditures. UR appears to reduce expenditures mainly by reducing admissions; hospital inpatient expenditures per admission were unaffected by the review activity. Analysis showed the effect of UR to have been greatest during the quarters immediately following implementation of the review activity. This finding underscores the need to analyze longitudinal data having sufficient time-series observations to obtain reliable estimates of long-term program impact. The analysis described here offers a computationally efficient alternative specification to the standard fixed-effects approach for analyzing pooled data, and is especially useful when the number of cross-section units is large.

Analysis of Variance↗
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

Comparison of state legislation regarding professional liability.

The so-called malpractice crisis of the mid-1970s alerted physicians to the need for legislative involvement in order to achieve needed malpractice tort reform. There has been a positive effort to modify the medical liability situation in each of our 50 states. A review of this legislative activity from 1975 through 1977 is presented. It is anticipated that a new malpractice crisis may develop during the early 1980s. Actuarial data now being collected plus the effects of such innovations as arbitration, pretrial screening panels, collateral source rules, and periodic funding of malpractice claims may provide an equitable approach to any future malpractice tort reform.

Humans↗
PubMed1992

Eye injuries associated with anesthesia. A closed claims analysis.

Claims against anesthesiologists for eye injuries were analyzed as part of the ASA Closed Claims Project. Eye injury occurred in 3% of all claims in the database (71 of 2,046). The payment frequency for eye injury claims was higher than that for non-eye injury claims (70% vs. 56%; P less than or equal to 0.05). The median cost of eye injury claims was less than that for other claims ($24,000 vs. $95,000; P less than or equal to 0.01). Two distinct subsets were identified. The first was characterized by corneal abrasion during general anesthesia (25 of 71 claims; 35%). Claims for corneal abrasion were characterized by low incidence of permanent injury (16%) and low median payment ($3,000). Reviewers were able to identify a mechanism of injury in only 20% of claims for corneal abrasion. The second subset of eye injury was characterized by patient movement during ophthalmologic surgery (21 of 71; 30%). Blindness was the outcome in all cases. Sixteen of the claims involving movement occurred during general anesthesia, and 5 occurred during monitored anesthesia care. The median payment for claim involving movement was 10 times greater than for non-movement claims ($90,000 vs. $9,000; P less than or equal to 0.01). Anesthesiologist reviewers deemed the care rendered in the general anesthesia "movement" claims as meeting standards in only 19% of claims. From the perspective of patient safety, as well as risk management, these data suggest two specific needs: research directed at better understanding of the etiology of corneal abrasion and clinical strategies designed to assure patient immobility during ophthalmic surgery.

Adult↗
PubMed1992

Green Spring criteria for medical necessity of outpatient treatment and its use in a mental health utilization review program.

The authors have developed a two-tiered method for utilization review of outpatient mental health services. The methodology looks at initial and continued treatment evaluation and uses diagnosis, symptoms, plan of treatment, and the Global Assessment Scale (GAS) among other indicators to determine appropriateness of treatment. Preliminary program experience has been positive and is included.

Ambulatory Care↗
PubMed1989

"Medically unnecessary" letters create frustrating puzzles.

Medicare's "medically unnecessary" letters are frustrating puzzles to the many Texas physicians who receive them. While the letters question the medical necessity of care, they provide physicians with no basis for understanding and responding to that allegation. Medicare uses computerized screens to review claims, and it is those screens that are primarily responsible for the generation of "medically unnecessary" letters. The accompanying list of Medicare review screens provides a general clarification of what Medicare is looking for in the review process. The word "general" is an important qualification: there is no guarantee that a physician will be able to identify from the list the particular screen that has caused Medicare to request more information about a particular claim. But the list will help the practitioner in understanding what Medicare sees as the boundaries of customary medical practice and, in some instances, will help the physician respond to Medicare's request for additional information. With that broad introduction Texas Medicine presents the following guide to Medicare's claims screening criteria. It was prepared by the Texas Medical Association's Division of Medical Economics based on materials published by Medicare.

Health Services↗