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Objectives. This study analyzed whether inadequate functional health literacy is an independent risk factor for hospital admission. Methods. We studied a prospective cohort of 3260 Medicare managed care enrollees. Results. Of the participants, 29.5% were hospitalized. The crude relative risk (RR) of hospitalization was higher for individuals with inadequate literacy (n = 800; RR = 1.43; 95% confidence interval [Cl] = 1.24, 1.65) and marginal literacy (n = 366; RR = 1.33; 95% Cl = 1.09, 1.61) than for those with adequate literacy (n = 2094). In multivariate analysis, the adjusted relative risk of hospital admission was 1.29 (95% Cl = 1.07, 1.55) for individuals with inadequate literacy and 1.21 (95% Cl=0.97, 1.50) for those with marginal literacy. Conclusions. Inadequate literacy was an independent risk factor for hospital admission among elderly managed care enrollees.

Prepayment audits are done by Medicare carriers to check if physicians are billing correctly. Several steps should be followed by physicians to lessen problems that will be encountered in claim audits. First, the physician's staff should be informed of carriers' request for records. Second, records should not be changed after physicians receive an order for them. Third, a self-audit should be conducted by the physician to anticipate the possible things that an auditor will look for. Fourth, all correspondence should be duly recorded and sent with a cover letter., Experts tell how to prepare for an audit, when to pay and be done with it, when to pay and appeal, and when to fight. If you're getting more requests [...]

Influenza and related pneumonia continue to cause significant amounts of morbidity and mortality despite the availability of effective vaccines. Two comparable counties in Massachusetts served as project areas of a national trial to see if reimbursement for immunizing Medicare-B eligible recipients against influenza would increase the use of the vaccine and reduce the costs attributed to related morbidity. Providers of health and social services to elders were recruited to participate in one county. A variety of professional and public education campaigns and media were used to promote influenza immunizations. Laboratory-based surveillance was instituted in both counties to assess the extent of circulating virus in each. Vaccine was made available to medical providers in both counties. While the amount of vaccine used in the comparison county increased by 6% from pre-project time (16,000 to 17,000 doses administered), vaccine use increased 219% in the intervention county (21,250 to 46,494 doses administered). In a post-project survey of participating physicians, 88% of 238 respondents reported administering less than 100 doses of influenza vaccine per year prior to the project. By the end of the project, only 32% administered less than 100 in the previous year. This project demonstrated the need for educating both the provider and the public in order to successfully promote immunizations. It was not clear, however, if reimbursement was a more important factor for promoting influenza immunizations than was universal distribution of free vaccine.

Americans are clamoring for health care reform as the realization grows that the US ranks lower than many other countries in the delivery of basic health care that would prevent many illnesses and deaths. An estimated 15% of the American population have no insurance to provide them with basic health care, and the number who have no dental insurance is almost three times as great. A national sampling of dentists who work in hospitals revealed that dental procedures covered by Medicare are not equally reimbursed. The problem lies with the lack of uniform guidelines and universal claim forms as well as inappropriate interpretation. Most of the 179 respondents whose questionnaires were analyzed favored medically adjunctive dental care as part of national health care reform. Only legislative action can solve the inequities of the Medicare system.

Objectives. This study sought to examine racial differences in the use of medical procedures and diagnostic tests by elderly Americans. Methods. We used 1986 physician claims data for a 5% national sample of Medicare enrollees aged 65 years and older to study 32 procedures and tests. For each service, we calculated the age-and sex-adjusted rate of use by race and the corresponding White-Black relative risk. Results. Whites were more likely than Blacks to receive 23 services, and for many of these services, the differences in use were substantial. In contrast, Blacks were more likely than Whites to receive seven services. White had a particular advantage in access to higher-technology or newer services. Racial differences in use persisted among elders who had Medicaid in addition to Medicare coverage and increased among rural elders. Conclusions. There are pervasive racial differences in the use of medical services by elderly Americans that cannot be explained by differences in the prevalence of specific clinical conditions. Financial barriers to care do not fully account for these findings. Race may exacerbate the impact of other barriers to access. (Am J Public Health. 1993;83:948-954), Almost all elderly Americans get health insurance through Medicare, and despite some gaps in coverage, it has expanded access to formerly underserved populations. To examine racial differences in the use of medical procedures and diagnostic tests by the elderly, data from 1986 physician claims were used for a 5% sample of Medicare enrollees 65 years of age and older to study 32 procedures and tests. Whites were found to be much more likely than Blacks to receive 23 services, and Blacks were more likely than Whites to receive seven. Whites had better access to high-tech or newer services. Even among blacks who had Medicaid as well as Medicare, the racial difference persisted and was most marked among elderly rural blacks. Although differences in the prevalence of specific clinical conditions alone cannot explain the racial differences in the use of medical services by the elderly, it may be that race exacerbates the effect of other barriers to access.

New rules governing Medicare claims require that physicians use evaluation-and-management codes, and the correct modifiers must be attached when special circumstances occur. The proper documentation must also be attached. Many problems exist with coding, and some feel that the system is confusing and that physicians have not received adequate instructions. The new system of coding is in no way related to the old system, and doctors who try to employ old methods will have their claims rejected., The tangle of old and new rules is confusing. But with Uncle Sam cracking down on rule-breakers, ignorance can be costly. A physician called Asheville, N.C. practice management consultant John [...]

Coding errors for hospitalized Medicare patients assigned to diagnosis related groups (DRG) declined from 20.8% in 1985 to 14.7%. In 1985, 61.6% of errors resulted in overreimbursement hospitals, increasing net reimbursement by 1.9%, or $308 million nationally. Coding errors are usually due to either a diagnosis not supported by the medical record, miscoding by the medical records department or substitution by hospital employees of a secondary diagnosis for a correctly coded principal diagnosis (resesquencing). By 1988, coding errors had been reduced to 6.1%. These errors did not overreimburse the hospitals. However the proportion of discharges overreimbursing hospitals has not changed, possibly due to resequencing . Coding errors which cause overreimbursement, DRG "creep", may have been diminished because of current requirements for the physician to certify the correctness of the patient's narrative diagnosis and procedures, requirements which do not exist for hospital personnel.

Physicians can reduce the time it takes to receive payments on Medicare and insurance claims by filing claims electronically. Some 25% of all claims are filed through electronic claims submission (ECS). ECS, also known as electronic data interchange, can reduce the cost of each claim by 50 cents to $1. Payroll costs may also be lowered because personnel spend less time filing claims. The two methods of ECS are the direct filing of claims through the carrier and the use of an electronic clearinghouse., If you want Medicare and other claims paid faster, while saving a lot of staff time and hassle, you've got to board the bandwagon of electronic claims submission. ECS is [...]

A study of 227,771 discharge abstracts from one U.S. state's short-term, acute care hospitals compares changes in the inpatient market available to the oldest old Medicare patients (85 and older) with those less than 70 and those 70-84 between 1981, the last year when all hospitals were under cost-based reimbursement, and 1984, the first year in which all hospitals were under a prospective payment system based on diagnosis related groups (DRGs). All three populations experienced retrenchment in services as hospitals pursued practice changes to enhance revenue potential. An older, sicker client was admitted as hospitals implemented changes in admission patterns to avoid denial of reimbursement for an admission deemed inappropriate by the Peer Review Organization (PRO). Evidence demonstrates compression in service markets and retrenchment in services for less profitable DRGs and/or cohorts. Inpatient services were reduced the most for the oldest old population although this cohort was the sickest. Changes were observed in utilization of special care units, such as in coronary and intensive care units. Large increases in readmissions in all three cohorts suggests that DRG incentives to reduce length of hospital stay may have promoted premature discharge. Or, perhaps these readmissions resulted from 'unbundling', a practice of splitting patient problems into multiple admissions, as hospitals sought ways to enhance revenue instead of practicing cost-containment. Policy, perceived to be economically stringent, can affect hospital practice and produce undesired results with long-reaching untoward effects on certain segments of the population.

This paper documents how extensively the component services Medicare carriers include in their global fees vary for four common operations. Although payment for each of the operations also varies substantially among Medicare carrier areas, differences in the extent of services included in the surgical global fee do not contribute to explaining the variations in payment. The recently enacted Medicare fee schedule based on resources can rationalize the current pattern of payments, but only if a uniform global service policy is implemented.

Congress's recent decision to pay primary care physicians more for treating Medicare patients will have implications for the relationship between physicians and private insurers as well. The approach taken in the Omnibus Budget Reconciliation Bill, passed in late 1989, was to limit funds paid by Medicare for 'cognitive care' - taking patients' histories, giving advice, or developing a treatment plan. A resource-based relative value scale (RBRVS), under which physicians' services are ranked according to the resource costs of providing them, was developed and has been endorsed by several physicians' associations. Changes include increases of 16 percent for internists, 37 percent for family practitioners, 7 percent for otolaryngologists, and 1 percent for obstetricians/gynecologists, with decreases of 21 percent for radiologists, 20 percent for thoracic surgeons, 17 percent for ophthalmologists, 10 percent for orthopedic surgeons, 9 percent for general surgeons, and 3 percent for urologists. The major points in the reform package are described. Growth of payments will be limited, but the Medicare program may become more stable, with more value placed on primary care. The phase-in of RBRVS will take five years, beginning in 1992. Relative values for services will be based on work, practice expenses (about half the cost, including non-physician personnel, office space, etc.), and costs of malpractice insurance, with certain adjustments for geographic differences in the cost of living so that rural and urban physicians' incomes will be more equal. Malpractice insurance costs will be based on the actuarial risks of different services. Doctors in Manhattan will lose, while those in Jefferson County, Missouri, will gain, partly as a result of enormous differences in current costs of procedures. Medicare's assignment policy (whether a physician agrees in advance to accept the Medicare rate) and controls on the volume of services offered to Medicare patients - something physicians have opposed - are discussed. The Agency for Health Care Research and Policy has been created to fund research on the clinical practice of medicine. The new Medicare payment plan reflects a move away from market-based determination of physician's fees, toward administrative regulation. Effects on private insurers are anticipated, but the nature of these effects is not known. The Health Care Financing Administration must develop a model fee schedule by September 1, 1990, and physicians would do well to expand their involvement in economic and political aspects of these decisions. (Consumer Summary produced by Reliance Medical Information, Inc.)

A widely acknowledged shortcoming of the current AAPCC capitation formula for Medicare HMOs is its inability to adjust capitation levels for differences in health status among enrolled groups. Prior use models have been proposed as one alternative to the current AAPCC risk classes. From 1984 through 1987, Senior Health Plan (SHP) participated in a HCFA-sponsored demonstration project in which capitation payments were determined by a prior use formula incorporating information on inpatient hospital days and Part B deductibles. This paper contains findings about selection bias in SHP enrollment fro analyses of preenrollment reimbursements and postenrollment mortality rates of SHP enrollees compared with Medicare FFS beneficiaries and enrollees of other Medicare HMOs in the Minneapolis-St. Paul area.

HOW TO MAKE YOURSELF A LIGHTNING ROD FOR MEDICARE In troubleshooting for physician clients, I've found that more than half their problems involve mistakes in billing Medicare. That's not surprising; [...]