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Results for “Insurance deductions”

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At least 19 recordsLinked to original sources
PubMed2026

Improving insurance deduction identification: a hybrid artificial intelligence model using machine learning and expert systems.

PURPOSE: Financial challenges in healthcare systems worldwide, especially in low- and middle-income countries like Iran, have increased hospitals' reliance on insurance reimbursements. Unrecognized insurance deductions often cause severe financial shortages, making efficient deduction management crucial. This study aimed to design a hybrid intelligent system for identifying and predicting insurance deductions by combining machine learning and expert system frameworks. DESIGN/METHODOLOGY/APPROACH: A mixed-methods design was applied in four stages. First, a scoping review identified the causes and patterns of insurance deductions. Second, interviews with 15 insurance experts produced a validated checklist and a dataset from inpatient billing records. Third, using the CRISP-DM methodology, machine learning algorithms were developed and tested in SPSS Modeler alongside a fuzzy expert system developed in MATLAB. Finally, the model was validated using the holdout method. FINDINGS: Four categories of deduction drivers were identified: service provision, registration errors, document submission issues, and revenue conversion processes. The CHAID decision tree outperformed other algorithms with a 99% precision rate and the lowest Mean Absolute Error (9.43). A brief assessment of potential overfitting was conducted to ensure that the CHAID model's high accuracy was interpreted cautiously and supported by the validation results. The fuzzy expert system with validated rules was adaptable for deduction classification, especially for cases unsuitable for quantitative modeling. ORIGINALITY/VALUE: The hybrid model improves detection and prevention of deductions, offering actionable insights for hospital administrators, insurers, and policymakers. Its implementation can enhance hospital information systems, streamline claims processing, and optimize revenue management amid financial constraints.

Machine Learning↗
PubMed1990

Waivers of insurance deductibles--charity or crime?

Many physicians occasionally waive insurance deductibles and copayments for their patients. Some do it routinely and advertise the fact. Aetna Life Insurance Company in 1988 called this practice fraud, a position The National Health Care Anti-Fraud Association subsequently took (1). However, it is all too easy to apply that label without analyzing the facts. This article examines the practice of waiving copayments and deductibles, describes recent developments in the area, and offers some guidelines for physicians.

Crime↗
PubMed1978

The norms hypothesis and the demand for medical care.

Our results cast doubt on the validity of the norms hypothesis--that physicians treat patients in accordance with the average or modal insurance coverage in an area. The one study in the literature directly supporting this hypothesis is misspecified; when more correctly specified, it provides no support for the hypothesis. Two versions of the hypothesis are distinguished. the stronger maintains that physicians do not take account of within-area variation in insurance coverage. This version is firmly rejected by the data. A weaker version says that the physician does take account of within-area variation but that between-area differences in average coverage have an independent effect on demand. Little or no support is found for this version, but our data do not permit very powerful tests.

Blue Cross Blue Shield Insurance Plans↗
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↗
PubMed1991

Liberal benefits, conservative spending. The Physicians for a National Health Program proposal.

The Physicians for a National Health Program proposes to cover all Americans under a single, comprehensive public insurance program without copayments or deductibles and with free choice of provider. Such a national health program could reap tens of billions dollars in administrative savings in the initial years, enough to fund generous increases in health care services not only for the uninsured, but for the underinsured as well. We delineate a transitional national health program budget that would hold overall health spending at current levels while accommodating increases in hospital and physician utilization. Future national health program spending would be indexed to the growth in gross national product adjusted for demographic, epidemiologic, and technologic shifts. Financing for the national health program would transfer funds into the public program without disrupting the general pattern of current revenue sources. We suggest a funding package that would augment existing government health spending with earmarked health care taxes. Because these new taxes would replace employer-employee insurance premiums and substantial portions of current out-of-pocket expenditures, they would not increase health costs for the average American.

Budgets↗
PubMed1991

Financial counseling for families of children with chronic disabilities.

A program to teach financial management skills to parents of children with chronic illnesses and disabilities was developed. To test the effectiveness of this program, a randomized, controlled prospective study was conducted of 115 families of children with spina bifida, 58 of whom received financial counseling while 57 served as controls. Significantly more frequent changes in behavior were found in the intervention group than in the control group at the end of the one-year study for 18 of the 68 variables, including such items as establishing records, using a budget, obtaining low-cost life insurance and taking appropriate tax deductions. Three-quarters of the families in the intervention group believe that the counseling program had had or would have a beneficial effect on the quality of their lives. Financial counseling may benefit families with chronically ill or disabled children.

Budgets↗