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Health Affairs (Project Hope) Jan 2022Little is publicly known about coverage denials for medical services that do not meet medical necessity criteria. We characterized the extent of these denials and their...
Little is publicly known about coverage denials for medical services that do not meet medical necessity criteria. We characterized the extent of these denials and their key features, using Medicare Advantage claims for a large insurer from the period 2014-19. In this setting, claims could be denied because of traditional Medicare's coverage rules or additional Medicare Advantage private insurer rules. We observed $416 million in denied spending, with 0.81 denials and $60 of denied spending per beneficiary annually. We found that 1.40 percent of services were denied and 0.68 percent of total spending was denied, with rates rising over time. Traditional Medicare's coverage rules accounted for 85 percent of denied services and 64 percent of denied spending; the remaining denials were due to additional Medicare Advantage insurer rules. Denial rates varied greatly across service type and provider type, with the most denials being for laboratory services and hospital outpatient providers. Traditional Medicare and Medicare Advantage insurer coverage policies each addressed different sources of medical spending; together they contributed to the denial of a modest but nontrivial portion of payments.
Topics: Aged; Government; Humans; Insurance Carriers; Medicare; Policy; United States
PubMed: 34982629
DOI: 10.1377/hlthaff.2021.01054 -
JAMA Nov 2023
Topics: Aged; Humans; Fee Schedules; Medicare; Medicare Part B; Physicians; Relative Value Scales; United States
PubMed: 37988095
DOI: 10.1001/jama.2023.18963 -
JAMA Nov 2023
Topics: Aged; Humans; Fees, Medical; Medicare; Physicians; United States
PubMed: 37988096
DOI: 10.1001/jama.2023.18960 -
JAMA Nov 2023
Topics: Aged; Humans; Medicare; United States; Fees, Medical; Physicians
PubMed: 37988092
DOI: 10.1001/jama.2023.18972 -
JAMA Nov 2023
Topics: Aged; Humans; Fees, Medical; Medicare; Physicians; United States
PubMed: 37988093
DOI: 10.1001/jama.2023.18969 -
JAMA Nov 2023
Topics: Aged; Humans; Fee Schedules; Medicare; Medicare Part B; Physicians; Relative Value Scales; United States
PubMed: 37988089
DOI: 10.1001/jama.2023.18975 -
American Journal of Clinical Pathology Apr 2021Quantifying pathologist participation in Medicare services may be informative for the prediction of future workforce needs and reimbursement.
OBJECTIVES
Quantifying pathologist participation in Medicare services may be informative for the prediction of future workforce needs and reimbursement.
METHODS
A retrospective examination was performed of pathologist professional (Part B) Medicare billings and payments from 2012 to 2017. The Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File was the primary data source.
RESULTS
From 2012 to 2017, there was an increase (3.7%; 11,215 up to 11,627) in pathologists providing Medicare Part B services. Female pathologists increased from 36.10% to 40.8% of pathologists during this time period. Normalized per pathologist, there was an increase (7.8%; 1,382 up to 1,489) in beneficiaries served as well as an increase (4.1%; 2,442 up to 2,543) in services performed. The top 10 pathology Part B services performed in a facility were all surgical pathology. Although services increased, the overall payment of Part B pathology services decreased (3%; $996,519,358 down to $966,615,856) during the study period.
CONCLUSIONS
Although there is increasing pathologist participation in Medicare, the workload per pathologist has increased.
Topics: Aged; Female; Humans; Medicare; Pathologists; Retrospective Studies; Sex Factors; United States; Workforce
PubMed: 33210114
DOI: 10.1093/ajcp/aqaa167 -
The American Journal of Geriatric... Jun 2024
Topics: Humans; United States; Medicare Part C; Health Expenditures; Medicare; Mental Disorders; Aged; Financial Stress
PubMed: 38350832
DOI: 10.1016/j.jagp.2024.01.227 -
Journal of the American Academy of... May 2024Medicare's legacy quality reporting programs were consolidated into the Merit-Based Incentive Payment System (MIPS) in 2015.
BACKGROUND
Medicare's legacy quality reporting programs were consolidated into the Merit-Based Incentive Payment System (MIPS) in 2015.
PURPOSE
The DataDerm registry of the American Academy of Dermatology was examined to understand the potential for and subsequent rate of improvement across 23 performance measures.
METHODS
We examined the level of performance across 23 performance measures with at least 20 clinicians reporting on at least 50 patients' experience. We calculated the following values: the aggregate performance rate for each measure and the overall aggregate performance rate.
RESULTS
The aggregate performance rate for each measure ranged from 20.4% for AAD 1 (Psoriasis: Assessment of Disease Activity), to 99.9% for measure ACMS 1 (Avoidance of Opioid Prescriptions for Reconstruction After Skin Resection). Three of 23 measures had an aggregate performance over 95%. The overall aggregate performance rate across all 23 measures was 81.2%, indicating an aggregate potential for improvement of 18.8% across the 23 measures. Nine performance measures reported across the first five years of DataDerm's existence were tracked through time to understand trends in performance through time. The performance across the nine performance measures meeting the inclusion criteria consistently improved in the initial years (2016 through 2018) of DataDerm participation and showed some variation in 2019 and 2020.
CONCLUSIONS
These data provide evidence that the very act of participation in a multi-institutional registry and tracking compliance with performance measures can lead to improvements in compliance with the performance measures and therefore improvements in quality of care.
Topics: Aged; Humans; United States; Medicare; Reimbursement, Incentive; Health Facilities; Motivation
PubMed: 38135157
DOI: 10.1016/j.jaad.2023.11.059 -
Journal of Health Politics, Policy and... Aug 2021Medicare initiatives have been instrumental in improving care delivery and payment as exemplified by its role in broadly expanding the use of telehealth during the...
Medicare initiatives have been instrumental in improving care delivery and payment as exemplified by its role in broadly expanding the use of telehealth during the COVID-19 pandemic. Medicare innovations have been adopted or adapted in Medicaid and by private payers, while Medicare Advantage plans successfully compete with traditional Medicare only because their payment rates are tied by regulation to those in the traditional Medicare program. However, Medicare has not succeeded in implementing new, value-based payment approaches that also would serve as models for other payers, nor has Medicare succeeded in improving quality by relying on public reporting of measured performance. It is increasingly clear that burdensome attention to measurement and reporting distracts from what could be successful efforts to actually improve care through quality improvement programs, with Medicare leading in partnership with providers, other payers, and patients. Although Congress is unlikely to adopt President Biden's proposals to decrease the eligibility age for Medicare or to adopt a public option based on Medicare prices and payment methods in the marketplaces, the Biden administration has an opportunity to provide overdue, strategic direction to the pursuit of value-based payments and to replace failed pay-for-performance with provider-managed projects to improve quality and reduce health disparities.
Topics: Delivery of Health Care; Health Policy; Humans; Medicare; Quality Improvement; Reimbursement Mechanisms; Telemedicine; United States
PubMed: 33493320
DOI: 10.1215/03616878-8970838