Implications of managed care denials for pediatric inpatient care.
With the growing penetration of managed care into the healthcare market, providers continue to experience increasing cost constraints. In this environment, it is important to track reimbursement denials and understand the managed care organization's rationale for refusal of payment. This is especially critical for providers of pediatric care, as children justifiably have unique healthcare needs and utilization patterns. We developed a system for tracking and documenting denials in our institution and found that health maintenance organizations denied claims primarily for one of three reasons: medically unnecessary care, care provided as a response to social (rather than medical) need, and provider inefficiencies. Health maintenance organization denials are also growing annually at our institutions. This knowledge can not only help providers of pediatric care more effectively negotiate future contracts, but provides an opportunity to differentiate the health needs of the pediatric patient from those of the adult. This information can be used as a basis for education, pediatric outcome studies, and guideline development--all tools that can help providers receive reasonable reimbursement for pediatric services and enable them to meet the complex health needs of children. Recommendations for action are discussed. (+info)
Differences in physician compensation for cardiovascular services by age, sex, and race.
The purpose was to determine whether physicians receive substantially less compensation from patient groups (women, older patients, and nonwhite patients) that are reported to have low rates of utilization of cardiovascular services. Over an 18-month period we collected information on payments to physicians by 3,194 consecutive patients who underwent stress testing an 833 consecutive patients who underwent percutaneous coronary angioplasty at the Yale University Cardiology Practice. Although the charges for procedures were not related to patient characteristics, there were large and significant differences in payment to physicians based on age, sex, and race. For example, physicians who performed percutaneous transluminal coronary angioplasty received at least $2,500 from, or on behalf of, 72% of the patients 40 to 64 years old, 22% of the patients 65 to 74 years old, and 3% of the patients 75 years and older (P < 0.001); from 49% of the men and 28% of the women (P < 0.001); and 42% of the whites and 31% of the nonwhites (P < 0.001). Similar differences were observed for stress testing. These associations were largely explained by differences in insurance status. (+info)
Uncompensated care and hospital conversions in Florida.
Hospital conversions to for-profit ownership have prompted concern about continuing access to care for the poor or uninsured. This DataWatch presents an analysis of the rate of uncompensated care provided by Florida hospitals before and after converting to for-profit ownership. Uncompensated care declined greatly in the converting public hospitals, which had a significant commitment to uncompensated care before conversion. Among converting nonprofit hospitals, uncompensated care levels were low before conversion and did not change following conversion. The study suggests that policymakers should assess the risk entailed in a conversion by considering the hospital's historic mission and its current role in the community. (+info)
Alternative funding policies for the uninsured: exploring the value of hospital tax exemption.
The tax exemption accorded private, nonprofit hospitals is being subjected to more scrutiny as the numbers of uninsured grow; meanwhile, charity care competes with market-driven priorities. Current public policies tie hospital tax exemption to the provision of charity care, but there is a gap in the size and distribution of values between tax exemption and the charity care that is provided. Most hospitals, in a study reported here, provided free care at a level below the value of their tax exemption, even when 50 percent of bad debt was included in the care value. However, hospitals in the poorest communities offered considerably more care than the value of their tax exemption, whereas those in wealthier communities offered considerably less. Policies at local, state, and federal levels should be designed to exert leverage on hospitals to provide free care at a level commensurate with the value of their tax exemptions. (+info)
Impact of managed MediCal on California family practice programs.
BACKGROUND: An important source of patients for California's family practice program is MediCal. During the past 5 years, MediCal has established a variety of capitated managed care plans. OBJECTIVE: To assess the impact of California's managed MediCal program on the state's 38 family practice training programs. DESIGN: A cross-sectional, retrospective descriptive survey. METHODS: A 3-page, 11-question survey was developed by family practice residency directors and staff from the California Academy of Family Physicians, San Francisco. The 38 family practice programs in existence in California in September 1997 were stratified by type of managed MediCal in their county and by type of sponsoring institution--university, county, community based, staff-model health maintenance organization, or managed care system. RESULTS: Of the 38 family practice programs, 27 responded; 19 of 27 programs participated in managed MediCal. The total number of family health center patients, and the percentage of MediCal patients (48%-60%) at family practice programs was similar when stratified by programs with and without managed MediCal and by type of sponsorship. Most programs reported that they were able to compete effectively, although most also reported increased administrative, nursing, and front office costs. Managed MediCal patients were directly assigned to residents in only 3 of 19 programs. CONCLUSIONS: The introduction of managed MediCal has not adversely affected the number of patients cared for in California's family practice programs. Continued vigilance regarding California family practice programs' involvement in managed MediCal, including collection of accurate data on the number of MediCal patients and the financial and educational implications for California's family practice programs, is warranted. (+info)
ADEA annual survey of clinic fees and revenue: 1998-1999 academic year.
The American Dental Education Association's 1998-1999 Survey of Clinic Fees and Revenue obtained data by which to report, by school, clinic revenue information per undergraduate student. Fifty of the fifty-five U.S. dental schools responded to the survey. The median revenue per third-year student was $6,313. It was $11,680 for fourth-year students. Clinic revenue data was also obtained by type of postdoctoral program. The postdoctoral general dentistry programs had the highest per student clinic revenues, at over $59,000 per AEGD student and almost $35,000 per student of GPR programs. Other areas of the survey provided information regarding clinic fees by type of program, levels of uncompensated care by type of program, clinic revenue by source of payment, and dental school fees as a percent of usual and customary private practice fees. (+info)
Primary care office policies regarding care of uninsured adult patients.
OBJECTIVE: To describe primary care office policies regarding care of uninsured patients. DESIGN: Telephone survey of all adult primary care sites advertising in the area telephone directory. Sites were defined by ownership status, number of physicians, use of physician-extenders, and location. Policies assessed were whether the site was accepting new uninsured patients, billing policies, the availability of free or discounted care, and payment plans. SETTING: Allegheny County, Pennsylvania. PARTICIPANTS: Of the 359 sites identified, 240 (66.9%) responded, representing 794 physicians. Survey respondents included receptionists (40.4%), office managers (36.2%), and physicians (22.9%). RESULTS: While the majority of all sites reported accepting new patients without health insurance (87.5%), policies regarding these patients varied significantly by ownership status and the number of physicians. Sites with 3 or fewer physicians were more likely to accept uninsured patients. Self-owned practices were more likely to require payment at the time of service, and provide discounted care, free care, and payment plans compared with hospital/health system practices or multisite group practices. CONCLUSIONS: Willingness to accept uninsured patients does not always equate to affordable or accessible care. Office policies have the potential to be substantial obstacles to primary care. (+info)
Impact of Medicare denials on noninvasive vascular diagnostic testing.
PURPOSE: The purpose of this study was to evaluate the impact of Medicare coverage limitations and claim denials on noninvasive vascular diagnostic testing. METHODS: All Medicare claims for noninvasive vascular diagnostic studies from January 1, 1999, to December 31, 1999, were identified from the hospital billing database according to Current Procedural Terminology codes for carotid artery duplex ultrasound scan, venous duplex ultrasound scan, and lower-extremity arterial Doppler scan. Reasons for Medicare denial of payment for these tests were reviewed and a cost analysis was performed. RESULTS: During the 1-year period, there were 1096 noninvasive vascular diagnostic studies performed on Medicare patients. Of these 1096 tests, 176 (16.1%) were denied by Medicare (19.6% of 408 carotid duplex ultrasound scans, 16.8% of 345 venous duplex ultrasound scans, and 11.1% of 343 lower-extremity arterial Doppler scans). Of the noninvasive vascular tests denied by Medicare, an abnormal result was present in 72.5% of carotid duplex ultrasound scans, 32.8% of venous duplex ultrasound scans, and 78.9% of lower-extremity arterial Doppler scans. Overall, 88.1% of all initially denied claims (N = 176) were ultimately reimbursed by Medicare after resubmission, including 77.1% of the 118 claims denied based on compliance rules for "medical necessity." CONCLUSION: Because of coverage limitations, Medicare denials of noninvasive vascular diagnostic tests can lead to potential uncompensated physician and hospital technical fees if denied claims are unrecognized. Vascular laboratories performing these tests need to review compliance with Medicare guidelines. Improvements may need to be made at both the provider and Medicare carrier levels in obtaining reimbursement for appropriately ordered noninvasive vascular diagnostic studies. (+info)