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Background: Ambulatory geriatric rehabilitation (AGR) is a multidisciplinary outpatient prevention program designed to decrease hospitalisation and dependence on nursing care in multimorbid patients ≥70 years of age. We evaluated the effectiveness of AGR compared to usual care on progression of nursing care levels, nursing home admissions, hospital admissions, incident fractures, mortality rate and total cost of care during a one-year follow-up period., Methods: Analyses were based on claims data from the health insurance company AOK Nordost. Propensity Score matching was used to match 4 controls to each person receiving the AGR intervention., Results: A total of 632 AGR participants and 2528 matched controls were included. The standardized mean difference of matching variables between cases and controls was small (mean: + 1.4%; range: - 4.4/3.9%). In AGR patients, the progression of nursing care levels (+ 2.2%, 95%CI: - 0.9 /5.3), nursing home admissions (+ 1.7%, 95%CI: - 0.1/3.5), hospital admissions (+ 1.1%, 95%CI: - 3.2/5.4), incident fractures (+ 11.1%, 95%CI: 7.3/15) and mortality rate (+ 1.2%, p = 0.20) showed a less favourable course compared to controls. The average total cost per AGR participant was lower than in the control group (- 353€, 95%CI: - 989€/282€), not including costs for AGR., Conclusions: Analysis based on claims data showed no clinical benefit from AGR intervention regarding the investigated outcomes. The slightly worse outcomes may reflect limitations in matching based on claims data, which may have insufficiently reflected morbidity and psychosocial factors. It is possible that the intervention group had poorer health status at baseline compared to the control group., Trial Registration: German Clinical Trials Register DRKS00008926, registered 29.07.2015.

Objective: We describe our experience in implementing enterprise-wide standardized structured reporting for chest radiographs (CXRs) via change management strategies and assess the economic impact of structured template adoption., Methods: Enterprise-wide standardized structured CXR reporting was implemented in a large urban health care enterprise in two phases from September 2016 to March 2019: initial implementation of division-specific structured templates followed by introduction of auto launching cross-divisional consensus structured templates. Usage was tracked over time, and potential radiologist time savings were estimated. Correct-to-bill (CTB) rates were collected between January 2018 and May 2019 for radiography., Results: CXR structured template adoption increased from 46% to 92% in phase 1 and to 96.2% in phase 2, resulting in an estimated 8.5 hours per month of radiologist time saved. CTB rates for both radiographs and all radiology reports showed a linearly increasing trend postintervention with radiography CTB rate showing greater absolute values with an average difference of 20% throughout the sampling period. The CTB rate for all modalities increased by 12%, and the rate for radiography increased by 8%., Discussion: Change management strategies prompted adoption of division-specific structured templates, and exposure via auto launching enforced widespread adoption of consensus templates. Standardized structured reporting resulted in both economic gains and projected radiologist time saved., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Real-world evidence (RWE) can inform patient management decisions, but RWE studies are associated with limitations. Linkage of different RWE data types could address such limitations by enriching data and improving scientific quality. Using the example of chronic obstructive pulmonary disease (COPD) in Germany, this study assessed the value of data linkage between primary and secondary data sources for RWE., Methods: Post hoc analysis of data from an observational RWE study, which used prospectively collected data and data from an insurance claims database to assess treatment adherence and persistence in patients with COPD in Germany. Patient-level primary data were collected from the prospective observational study (primary dataset, N = 636), and claims data from the sickness fund AOK Nordost (claims dataset, N = 74,916). Primary and claims data were linked at a patient level using insurance numbers (linked dataset). Patients in the linked dataset were indexed at date of study inclusion for primary data and matched calendar date for claims data. Agreement between primary and claims data was examined for patients in the linked dataset based on comparisons between recorded sociodemographic data at index, comorbidities (primary: any recorded; claims: pre-index), prescriptions for COPD therapies (type and date) and exacerbations in the 12-month post-index period., Results: The linked dataset included primary and claims data for 536 patients. Fewer comorbid patients were reported in primary data compared with claims data (p < 0.001), with overall agreement between 63.6% (hypertension) and 90.5% (osteoporosis). Number of prescriptions for COPD therapies per patient was lower in primary versus claims data (3.7 vs 10.3 prescriptions, respectively), with only 24.5% of prescriptions recorded in both datasets. Only 11.5% of exacerbations (moderate or severe) were recorded in both datasets, with 15.5% recorded only in primary data and 73.0% recorded only in claims data., Conclusion: Our study highlighted discrepancies between primary and claims data capture for this population of German patients with COPD, with lower reporting of comorbidities, COPD therapy prescriptions and exacerbations in primary versus claims data. Study findings suggest that data linkage of primary and claims data could provide enrichment and be useful in fully describing COPD endpoints.

Background: Administrative claims of United States Centers for Medicare and Medicaid Services (CMS) beneficiaries have long been used in non-experimental research. While CMS performs in-house checks of these claims, little is known of their quality for conducting pharmacoepidemiologic research. We performed exploratory analyses of the quality of Medicaid and Medicare data obtained from CMS and its contractors., Methods: Our study population consisted of Medicaid beneficiaries (with and without dual coverage by Medicare) from California, Florida, New York, Ohio, and Pennsylvania. We obtained and compiled 1999-2011 data from these state Medicaid programs (constituting about 38% of nationwide Medicaid enrollment), together with corresponding national Medicare data for dually-enrolled beneficiaries. This descriptive study examined longitudinal patterns in: dispensed prescriptions by state, by quarter; and inpatient hospitalizations by federal benefit, state, and age group. We further examined discrepancies between demographic characteristics and disease states, in particular frequencies of pregnancy complications among men and women beyond childbearing age, and prostate cancers among women., Results: Dispensed prescriptions generally increased steadily and consistently over time, suggesting that these claims may be complete. A commercially-available National Drug Code lookup database was able to identify the dispensed drug for 95.2-99.4% of these claims. Because of co-coverage by Medicare, Medicaid data appeared to miss a substantial number of hospitalizations among beneficiaries ≥ 45 years of age. Pregnancy complication diagnoses were rare in males and in females ≥ 60 years of age, and prostate cancer diagnoses were rare in females., Conclusions: CMS claims from five large states obtained directly from CMS and its contractors appeared to be of high quality. Researchers using Medicaid data to study hospital outcomes should obtain supplemental Medicare data on dual enrollees, even for non-elders., Trial Registration: Not applicable.

The seven deadly sins, also known as the capital vices or cardinal sins, is a list of vices of Christian origin. They are hubris, greed, lust, malicious envy, gluttony, anger, and sloth. Likewise, there are deadly sins (mistakes) that have a negative impact on the medical practice. This article discusses the deadly sins of a medical practice and what each physician and each practice manager can do to combat those sins or mistakes.

Providers have just one last chance to prepare for implementation of ICD-0. These three components are key to a successful transition: Strong leadership, proactive processes and technology, diligence with denials.

We describe the results of a survey of claim forms that are used when starting rehabilitation following inpatient treatment and of an evaluation of a claim form developed on the basis of the results. The survey of different existing forms shows a high overlapping in content, suggesting the possibility of unification to one claim form that can be accepted by all insurers. In analogy to the Delphi method criteria for evaluation were consented and applied by the author group to assess the relevance of the claim forms content items for the process of initiating rehabilitation. A group of further experts added their evaluations. We prioritised the results and extracted the essential contents to conceive a unified claim form eligible for all types of rehabilitation. The claim form was discussed in 3 focus groups, revised accordingly and tested in the Hannover Medical School. Test results show that all relevant information is asked for and that the form is well manageable. The users' request for an IT-based solution and further ideas for improvement were integrated into the revised and validated version of the claim form. It is now available for all stake holders, in particular for insurers, as a means to improve quality of care and efficiency by standardisation of rehabilitation claim forms., (© Georg Thieme Verlag KG Stuttgart · New York.)

Payment denials based on questions of medical necessity have increased significantly for many hospitals, while the odds of mounting a successful appeal have diminished. Instead of focusing primarily on making appeals more effective, hospitals should construct a strategy for reducing the incidence of medical-necessity denials through the collection and analysis of denials data. Hospitals can break down the data to produce optimal approaches at both the case management and service levels to minimizing lost revenue from medical-necessity denials.

Background: Health care claims data may provide a cost-efficient approach for studying chronic kidney disease (CKD)., Study Design: Prospective cohort study., Setting & Participants: We compared characteristics and outcomes for individuals with CKD defined using laboratory measurements versus claims data from 6,982 REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study participants who had Medicare fee-for-service coverage., Predictors: Presence of CKD as defined by both the REGARDS Study (CKDREGARDS) and Medicare data (CKDMedicare), presence of CKDREGARDS but not CKDMedicare, and presence of CKDMedicare but not CKDREGARDS, and absence of both CKDREGARDS and CKDMedicare., Outcomes: Mortality and incident end-stage renal disease (ESRD)., Measurements: The research study definition of CKD (CKDREGARDS) included estimated glomerular filtration rate (eGFR) < 60mL/min/1.73m(2) or albumin-creatinine ratio > 30mg/g at the REGARDS Study visit. CKD in Medicare (CKDMedicare) was identified during the 2 years before each participant's REGARDS visit using a claims-based algorithm., Results: Overall, 32% of participants had CKDREGARDS and 6% had CKDMedicare. Sensitivity, specificity, and positive and negative predictive values of CKDMedicare for identifying CKDREGARDS were 15.5% (95% CI, 14.0%-17.1%), 97.7% (95% CI, 97.2%-98.1%), 75.6% (95% CI, 71.4%-79.5%), and 71.5% (95% CI, 70.4%-72.6%), respectively. Mortality and ESRD incidence rates, expressed per 1,000 person-years, were higher for participants with versus without CKDMedicare (mortality: 72.5 [95% CI, 61.3-83.7] vs 33.3 [95% CI, 31.5-35.2]; ESRD: 16.4 [95% CI, 11.2-21.6] vs 1.3 [95% CI, 0.9-1.6]) and with versus without CKDREGARDS (mortality: 59.9 [95% CI, 55.4-64.4] vs 25.5 [95% CI, 23.6-27.4]; ESRD: 6.8 [95% CI, 5.4-8.3] vs 0.1 [95% CI, 0.0-0.3]). Among participants with CKDREGARDS, those with abdominal obesity, diabetes, anemia, lower eGFR, more outpatient visits, hospitalization, and a nephrologist visit in the 2 years before their REGARDS visit were more likely to have CKDMedicare., Limitations: CKDREGARDS relied on eGFR and albuminuria assessed at a single visit., Conclusions: CKD, whether defined in claims or through research study measurements, was associated with increased mortality and ESRD. However, individuals with CKD identified in claims may represent a select high-risk population., (Copyright © 2015 National Kidney Foundation, Inc. All rights reserved.)

Background: Claims-based quality profiles are increasingly used by third-party payers as a means of monitoring and remunerating physician performance. As traditional approaches to assessing performance yield to electronically generated data, identifying practice tools capable of influencing the behavior of these measures becomes essential to effectively managing medical practices., Purpose: The aim of this study was to examine the effect of using office system tools (i.e., patient registries, physician reminders, and flow sheets) and health information technology (HIT) on claims-based quality profile scores in primary care practices., Methodology: We analyzed survey responses from primary care physicians (n = 191) regarding their use of office system tools and HIT. These responses were linked to quality profile scores obtained from a Blue Cross Blue Shield of Texas claims-based data set., Findings: Elevated quality profile scores were associated with physicians who reported higher use of HIT. In addition, the influence of one office system tool, physician reminders, was contingent upon the availability and use of HIT., Practice Implications: Our findings indicate that primary care practices that fail to implement or use HIT appropriately will fare poorly in systems that monitor and reward performance based on measures derived from claims data. Linking prompts or reminders directly to clinical actions that influence quality indicators endorsed by payers should be a component of quality assurance programs.

Objective: To compare the performance of two new approaches to risk adjustment that are free of the influence of observational intensity with methods that depend on diagnoses listed in administrative databases., Setting: Administrative data from the US Medicare program for services provided in 2007 among 306 US hospital referral regions., Design: Cross sectional analysis., Participants: 20% sample of fee for service Medicare beneficiaries residing in one of 306 hospital referral regions in the United States in 2007 (n = 5,153,877)., Main Outcome Measures: The effect of health risk adjustment on age, sex, and race adjusted mortality and spending rates among hospital referral regions using four indices: the standard Centers for Medicare and Medicaid Services--Hierarchical Condition Categories (HCC) index used by the US Medicare program (calculated from diagnoses listed in Medicare's administrative database); a visit corrected HCC index (to reduce the effects of observational intensity on frequency of diagnoses); a poverty index (based on US census); and a population health index (calculated using data on incidence of hip fractures and strokes, and responses from a population based annual survey of health from the Centers for Disease Control and Prevention)., Results: Estimated variation in age, sex, and race adjusted mortality rates across hospital referral regions was reduced using the indices based on population health, poverty, and visit corrected HCC, but increased using the standard HCC index. Most of the residual variation in age, sex, and race adjusted mortality was explained (in terms of weighted R2) by the population health index: R2=0.65. The other indices explained less: R2=0.20 for the visit corrected HCC index; 0.19 for the poverty index, and 0.02 for the standard HCC index. The residual variation in age, sex, race, and price adjusted spending per capita across the 306 hospital referral regions explained by the indices (in terms of weighted R2) were 0.50 for the standard HCC index, 0.21 for the population health index, 0.12 for the poverty index, and 0.07 for the visit corrected HCC index, implying that only a modest amount of the variation in spending can be explained by factors most closely related to mortality. Further, once the HCC index is visit corrected it accounts for almost none of the residual variation in age, sex, and race adjusted spending., Conclusion: Health risk adjustment using either the poverty index or the population health index performed substantially better in terms of explaining actual mortality than the indices that relied on diagnoses from administrative databases; the population health index explained the majority of residual variation in age, sex, and race adjusted mortality. Owing to the influence of observational intensity on diagnoses from administrative databases, the standard HCC index over-adjusts for regional differences in spending. Research to improve health risk adjustment methods should focus on developing measures of risk that do not depend on observation influenced diagnoses recorded in administrative databases.

Intermountain Healthcare's journey toward a modern revenue integrity process began with five key steps: building a multidisciplinary team, developing department-specific charge-capture teams, providing ongoing education and training on best practices for revenue integrity, leveraging new technology and business support services, establishing a proactive approach to managing audits and compliance.

Many different claim forms are used when starting rehabilitation following inpatient treatment, resulting in high administrative overheads for hospital staff, financial institutions and government agencies as well as patient allocation inefficiencies. We describe the problems ensuing on multiple and incompatible claim forms. On the basis of a survey of extant forms, we describe the content of a unified claim form that can be accepted by all insurers and which is optimised for hospital use. A model procedure for the development of a nationwide unified claim form allows for the assessment of the task's complexity and duration. Nevertheless, quality of care and efficiency considerations support a recommendation of standardisation of rehabilitation claim forms. On this basis the authors appeal to all relevant health-care players to enter into the enterprise of standardisation and to pursue this goal consistently., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Initial symptoms of amyotrophic lateral sclerosis (ALS) are often subtle and can delay diagnosis. This exploratory analysis was conducted to better characterize the pre-diagnosis pathway undertaken by patients with ALS in the US Centers for Medicare & Medicaid Services Medicare longitudinal claims database., Methods: Quarterly Medicare claims data were analyzed to determine the pre-diagnosis pathway for an ALS patient cohort that included patients aged ≥ 65 years with ≥ 2 ALS claims (International Classification of Diseases, Ninth Revision, Clinical Modification code 335.20) between the first quarter of 2007 and the fourth quarter of 2009, and were enrolled in Medicare ≥ 2 years before the first ALS claim (diagnosis). A cohort of Medicare patients without claims for motor neuron diseases were identified for comparison. A subset of these patients with ≥ 3 years of claims data was included in a time to diagnosis analysis. Data extraction included the most common initial symptoms of ALS, the time from first ALS symptom to diagnosis, and the diagnostic procedures performed before the diagnosis of ALS., Results: A total of 399 patients met the inclusion criteria and were included in the ALS cohort; 272 patients were included in the time to diagnosis cohort. Before the quarter of diagnosis, symptoms that were more frequently seen in the ALS cohort than the general Medicare cohort included muscle weakness, lack of coordination and speech/swallowing difficulties. Limb-onset ALS (74%) was more common than bulbar-onset ALS (17%). Median time to diagnosis for limb- and bulbar-onset patients was 2.5 years and 1.25 years, respectively. The most common tests conducted before the quarter of diagnosis included sensory and motor nerve conduction tests, imaging studies, and electromyography; however, a substantial number of patients did not receive any nerve conduction testing. Motor nerve conduction testing in patients with bulbar-onset ALS had the largest impact on time to diagnosis., Conclusions: This analysis describes a diagnostic delay for patients with ALS in the US Medicare population, similar to previous reports. The development of tools and ongoing education that can help to identify patients with ALS earlier in their disease course is needed.

Hospitals should routinely perform internal audits of all functions affecting billing accuracy to mitigate the effects of payer audits and to protect revenue by improving billing processes. A primary focus for internal audits should be on coding accuracy, because coding errors leading to denials often reflect gaps in coders' knowledge or training. Effective communication between coding and denials management professionals is a critical success factor. Audits should support appeals processes, and audit findings should be used in educational initiatives aimed at improving coding accuracy.

Healthcare organizations should address physician clinical documentation improvement now, before the Oct. 1, 2014, implementation deadline for ICD-10, if they are to mitigate risk related to ICD-10 and optimize operational processes. Improving documentation now will have an immediate effect on revenue and will minimize the potential for losses related to denied claims after ICD-10 goes into effect. Training of physicians should not be just a "once-and-done" process. Organizations should plan now for training to continue even after the implementation deadline.

Under a recent CMS ruling, hospitals that have been denied payment for Medicare Part A services have the option to submit follow-up claims to Medicare Part B for some of these denied services. A CMS proposed rule threatens to remove that option by imposing barriers to the rebilling of claims denied under Part Afor payment under Part B. By commenting on the rule, hospitals may be able to persuade CMS to reject the proposed rule and, instead, adopt a policy similar to that in the ruling. Should CMS decide to finalize the rule, hospitals can use their comments in efforts either to convince Congress to enact statutory changes that would mandate expanded Part B rebilling or to challenge the final rule in litigation.