Generic dispensing rates for substitutable drugs prescribed by general practitioners compared with other private ambulatory specialists: A study based on a French national reimbursement database.

BACKGROUND: The use of generic drugs is a way for healthcare systems to reduce costs, particularly in ambulatory care. Several studies suggest that the prescriber's speciality is associated with the use of generic drugs, and that substitutable drugs prescribed by General Practitioners (GPs) are more often generic, but this association has never been studied in France. In the French legislative context, except in rare situations, all substitutable drugs prescribed should be dispensed in generic form. OBJECTIVES: Compare the generic drugs dispensing rate among substitutable drugs dispensed in community pharmacies prescribed by French private GPs with that of other private specialists, all other specialities combined (first objective) or each other speciality taken individually (second objective). METHODS: We used a sample of an open available semi-aggregated database from the 2019 French health insurance system database. We compared with logistic regression models GPs to all other specialities combined, then GPs to the 19 other specialties taken individually, only on the substitutable drugs they prescribe in common. RESULTS: In 2019, 53.4% of the drugs prescribed by French private ambulatory physicians were substitutable drugs, and 81.5% of them were dispensed in generic form. After adjustment, the generic dispensing rate for substitutable drugs was significantly higher for GPs than for other specialties (ORa 0.74 [IC95% 0.72-0.76]). Thirteen of the nineteen other specialities taken individually, such as endocrinologists (ORa 0.64 [IC95% 0.57-0.72]) and cardiologists (ORa 0.60 [0.56-0.63]) had significantly lower generic dispensing rates than GPs. No other speciality had a rate significantly higher than GPs. CONCLUSIONS: Substitutable drugs prescribed by French private GPs are more often dispensed in generic form than those from other private ambulatory specialties. To understand this result and optimise the use of generic drugs in outpatient settings, we need to study the different stages of drug use, from prescription by the physician to dispensing by the pharmacist and acceptance by the patient.

82% of substitutable drugs prescribed by French private general practitioners in 2019 were dispensed in generic form.No other ambulatory specialty rated significantly higher than general practitioners.Research is needed to study reasons for non-generic drug prescription in the context of legislative changes.

Assessment of national reimbursement anticancer medications availability in China: based on a medical institution perspective.

BACKGROUND: High clinical value national reimbursement anticancer medications (NRAMs) are pivotal treatments for patients with cancer. However, the availability of NRAMs in medical institutions is unknown. This study aimed to assess the availability of NRAMs in national and provincial medical institutions. METHODS: This cross-sectional study utilized national health insurance data to access the availability of NRAMs in national and provincial medical institutions. Further statistical analyses and visualizations were conducted in terms of medical institution level and daily cost. Using the Spearman's rank correlation test (α = 0.05), we calculated the correlation between the availability rates of NRAMs and their negotiation access time, daily cost, per capita disposable income, provincial gross product, and number of policy releases. RESULTS: Overall, 81 NRAMs, with an average availability rate of approximately 1.01% nationwide, were included. There were significant differences between provinces for each drug, and the availability of NRAMs gradually decreased in tertiary (13.41%), secondary (1.58%), and primary medical institutions (< 0.05%). Differences were also observed in the availability rate of NRAMs in various daily drug cost ranges. Among the factors examined, negotiation access time (r1 = 0.425), daily cost (r2 = - 0.326), per capita disposable income (r3 = 0.645), provincial gross product (r4 = 0.433), and number of policy releases (r5 = 0.461) were all correlated with the availability of NRAMs. CONCLUSIONS: The low availability of NRAMs in national and provincial medical institutions indicates that their willingness to equip NRAMs needs to be improved. All factors examined in this study affected the availability of NRAMs. Our findings can guide policymakers in improving relevant policies.

Interrupted time series analysis of chronic periodontitis-related procedures before and after the scaling reimbursement policy in Korea.

AIM: To study the use of a quasi-experimental design to assess the effects of scaling reimbursement policies on the incidence of chronic-periodontitis procedures. MATERIALS AND METHODS: Interrupted time series analysis was used to compare the effects before and after policy implementation using data on the number of periodontitis-related procedures from the Korean National Health Insurance Service-National Sample Cohort (n = 740,467) and the Health Screening Cohort (n = 337,904). Periodontitis-related procedures with diagnosis codes were categorized into basic (scaling or root planing), intermediate (subgingival curettage) and advanced (tooth extraction, periodontal flap surgery, bone grafting for alveolar bone defects or guided tissue regeneration). Subjects' demographics and comorbidities were considered. The incidence rate of immediate changes and gradual effects before and after policy implementation was assessed. RESULTS: Following the policy implementation from July 2013, an immediate increase was observed in total and basic procedures. No significant changes were noted in intermediate and advanced procedures initially. A decrease in the slope of intermediate procedures was observed in both databases. Advanced procedures showed varied trends, with no change in the National Sample Cohort but an increase in the Health Screening Cohort, particularly among subjects with comorbidities. CONCLUSIONS: Following the new policy implementation, the number of intermediate procedures decreased while the number of advanced procedures increased, especially among patients with comorbidities. These findings offer valuable insights on policy evaluation.

Insurance Reimbursement for Special Foods and Phenylalanine Levels in Patients With PKU in China.

Importance: Recent changes in China's social medical insurance reimbursement policy have impacted the financial burden of patients with phenylketonuria (PKU) for special foods. However, whether this policy change is associated with their blood phenylalanine (PHE) concentration is unclear. Objective: To investigate the association between the reimbursement policy and blood PHE concentration in patients with PKU. Design, Setting, and Participants: This cohort study measured the blood PHE concentrations of 167 patients with PKU across 4 newborn screening centers in China from January 2018 to December 2021. The reimbursement policy for special foods for patients with PKU at 2 centers was canceled in 2019 and restored from 2020 onwards. In contrast, the other 2 centers consistently implemented the policy. Data were analyzed from September 10 to December 6, 2023. Exposures: The implementation and cancelation of the reimbursement policy for special foods of patients with PKU. Main Outcomes and Measures: The blood PHE concentration was regularly measured from 2018 to 2021. A 1-sided Z test was used to compare the mean of the blood PHE concentration between different years. Results: Among 167 patients with PKU (mean [SD] age, 84.4 [48.3] months; 87 males [52.1%]), a total of 4285 measurements of their blood PHE concentration were collected from 2018 to 2021. For patients at the center that canceled the reimbursement policy in 2019, the mean (SD) of the blood PHE concentrations in 2019 was 5.95 (5.73) mg/dL, significantly higher than 4.84 (4.11) mg/dL in 2018 (P < .001), 5.06 (5.21) mg/dL in 2020 (P = .006), and 4.77 (4.04) mg/dL in 2021 (P < .001). Similarly, for patients at the other center that canceled the policy in 2019, the mean (SD) of the blood PHE concentrations in 2019 was 5.95 (3.43) mg/dL, significantly higher than 5.34 (3.45) mg/dL in 2018 (P = .03), 5.13 (3.15) mg/dL in 2020 (P = .003), and 5.39 (3.46) mg/dL in 2021 (P = .03). On the contrary, no significant difference was observed between any of the years for patients at the 2 centers that consistently implemented the policy. Conclusions and Relevance: In this cohort study of patients with PKU from multiple centers, the implementation of the reimbursement policy for special foods was associated with controlling the blood PHE concentration. Special foods expenditure for patients with PKU should be included in the scope of long-term social medical insurance reimbursement.

Unveiling the Hidden Discrepancies Between Medicare Physician Reimbursement Rates and Inflation Across Different Surgical Specialties.

OBJECTIVE: This study aimed to analyze the trends of Medicare physician reimbursement from 2011 to 2021 and compare the rates across different surgical specialties. BACKGROUND: Knowledge of Medicare is essential because of its significant contribution in physician reimbursements. Previous studies across surgical specialties have demonstrated that Medicare, despite keeping up with inflation in some areas, has remained flat when accounting for physician reimbursement. STUDY DESIGN: The Physician/Supplier Procedure Summary data for the calendar year 2021 were queried to extract the top 50% of Current Procedural Terminology codes based on case volume. The Physician Fee Schedule look-up tool was accessed, and the physician reimbursement fee was abstracted. Weighted mean reimbursement was adjusted for inflation. Growth rate and compound annual growth rate were calculated. Projection of future inflation and reimbursement rates were also calculated using the US Bureau of Labor Statistics. RESULTS: After adjusting for inflation, the weighted mean reimbursement across surgical specialties decreased by -22.5%. The largest reimbursement decrease was within the field of general surgery (-33.3%), followed by otolaryngology (-31.5%), vascular surgery (-23.3%), and plastic surgery (-22.8%). There was a significant decrease in median case volume across all specialties between 2011 and 2021 (P < 0.001). CONCLUSIONS: This study demonstrated that, when adjusted for inflation, over the study period, there has been a consistent decrease in reimbursement for all specialties analyzed. Awareness of the current downward trends in Medicare physician reimbursement should be a priority for all surgeons, as means of advocating for compensation and to maintain surgical care feasible and accessible to all patients.

Quantified trends in provider reimbursement and utilization volume in colorectal cancer screenings: analysis of Medicare claims from 2000 to 2019.

AIM: Colorectal cancer (CRC) screening rates in the United States remain persistently below guideline targets, partly due to suboptimal patient utilization and provider reimbursement. To guide long-term national utilization estimates and set reasonable screening adherence targets, this study aimed to quantify trends in utilization of and reimbursement for CRC screenings using Medicare claims. METHOD: Inflation-adjusted reimbursements and utilization volume associated with each CRC screening code were abstracted from Medicare claims between 2000 and 2019. Screenings, screenings/100 000 enrolees and reimbursement/screening were analysed with linear regression and compared with the equality of slopes tests. Average reimbursement per screening was compared using analysis of variance with Dunnett's T3 multiple comparisons test. RESULTS: The growth rate of multitarget stool DNA tests (mt-sDNA)/100 000 was the highest at 170.4 screenings/year (R2 = 0.99, p ≤ 0.001), while that of faecal occult blood tests/100 000 was the lowest at -446.4 screenings/year (R2 = 0.90, p ≤ 0.001) (p ≤ 0.001). Provider reimbursements averaged $546.95 (95% CI $520.12-$573.78) per mt-sDNA screening, significantly higher than reimbursements for all invasive screenings. Only FOBTs significantly increased in reimbursement per screening at $0.62/year (R2 = 0.91, p ≤ 0.001). CONCLUSION: We derived forecastable trend numbers for utilization and provider reimbursement. Faecal immunochemical tests/100 000 and mt-sDNA screenings/100 000 increased most rapidly during the entire study period. The number of nearly all invasive screenings/100 000 decreased rapidly; the number of colonoscopies/100 000 increased slightly, probably due to superior diagnostic strength. These trends indicate the that replacement of other invasive modalities with accessible noninvasive screenings will account for much of future screening behaviour and thus reductions in CRC incidence and mortality, especially given providers' reimbursement incentive to screen average-risk patients with stool-based tests.

Association of Medicaid Reimbursement Policies with Provision of Long-Acting Reversible Contraception in the Postpartum Period, 2012-2018.

Background: To address reimbursement challenges associated with long-acting reversible contraception (LARC) in the postpartum period, state Medicaid programs have provided additional payments ("carve-outs"). Implementation has been heterogeneous, with states providing separate payments for the device only, procedure only, or both the device and procedure. Methods: Claims data were drawn from 210,994 deliveries in the United States between 2012 and 2018. Using generalized estimating equations, we assess the relationship between Medicaid carve-out policies and the likelihood of LARC placement at (1) 3 days postpartum, (2) 60 days postpartum, and (3) 1 year postpartum, in Medicaid and commercially insured populations. Results: Among Medicaid beneficiaries, the likelihood of receiving LARC was higher in states with any carve-out, compared with states without carve-outs, at 3 days (adjusted odds ratio [aOR] 1.49 [95% confidence interval: 1.33-1.67], p < 0.001), 60 days (aOR: 1.40 [95% CI: 1.35-1.46], p < 0.001), and 1 year postpartum (aOR: 1.15 [95% CI: 1.11-1.20], p < 0.001). Adjustments were made for geographic region, seasonality, and patient age. Heterogeneity was observed by carve-out type; device carve-outs were consistently associated with greater likelihood of postpartum LARC placement, compared with states with no carve-outs. Similar trends were observed among commercially insured patients. Conclusion: Findings support the effectiveness of Medicaid carve-outs on postpartum LARC provision, particularly for device carve-outs, which were associated with increased postpartum LARC placement at 3 days, 60 days, and 1 year postpartum. This outcome suggests that policies to address cost-related barriers associated with LARC devices may prove most useful in overcoming barriers to immediate postpartum LARC placement, with the overarching aim of promoting reproductive autonomy.

State Coverage and Reimbursement of Antiobesity Medications in Medicaid.

This study examines state Medicaid coverage policies for antiobesity medications and their trends in Medicaid reimbursement from 2011 to 2022.

Meniscectomy Reimbursement and Utilization Are Declining at Different Rates Across the United States.

PURPOSE: To evaluate how arthroscopic meniscectomy utilization, reimbursement, physician billing practices, and patient populations have changed within the Medicare population from 2013 to 2021 at a national level and regional level. METHODS: The Medicare Physician & Other Practitioners database was queried for all episodes of 2-compartment and single-compartment arthroscopic meniscectomy between 2013 and 2021. Utilization per 10,000 beneficiaries and average inflation-adjusted reimbursement were assessed. Physician practice styles, measured through changes in the services billed, and Medicare beneficiary demographic characteristics were extracted each year. The Kruskal-Wallis test was performed to compare regions. RESULTS: Between 2013 and 2021, two-compartment meniscectomy utilization per 10,000 Medicare beneficiaries declined by 54.9% and single-compartment meniscectomy utilization declined by 54.2%. Average reimbursement declined by 9.3% and 12.5% for 2-compartment meniscectomy and single-compartment meniscectomy, respectively. In 2021, the South had the highest utilization of both 2-compartment (3.8/10,000) and single-compartment (4.7/10,000) meniscectomies while having the lowest average reimbursement for 2-compartment meniscectomy ($383.02, P < .001). Nationally, the average number of beneficiaries per surgeon performing single-compartment meniscectomy declined by 3.8% whereas the average number of billable services performed per beneficiary increased by 46.6%. The comorbidity risk score of these patients decreased by 8.7%, with the West having the healthiest patients in 2021. CONCLUSIONS: Meniscectomy utilization and reimbursement have been declining nationally within the Medicare population. Surgeons in the South performed the most meniscectomies while having among the lowest reimbursement. The practice patterns of surgeons performing meniscectomies have been changing, with surgeons performing nearly 50% more total billable services per beneficiary while performing fewer unique billable services. Additionally, the patient population of surgeons who perform meniscectomy was healthier in 2021 than in 2013. CLINICAL RELEVANCE: This study highlights changes in meniscectomy utilization and reimbursement over time in the face of changing evidence of meniscectomy use in elderly patients and new Medicare legislature regarding reimbursement.

Examining the Impact of the Current Reimbursement Regulation on Patient Access to Innovative Medical Devices in Taiwan: Insights From 8 Years' Reimbursement Data.

OBJECTIVES: This study aimed to assess the impact of the reimbursement regulation of medical devices (Regulation), introduced by the National Health Insurance Administration (NHIA) in 2013, on patients' access to innovative medical devices in Taiwan. METHODS: Analysis of the amount of time needed from application for NHIA reimbursement for new medical devices to receiving the decision from NHIA was done using the nonreimbursement product list featured on the NHIA website. Additionally, Welch analysis of variance was used to compare the amount of time it took from application to NHIA with reimbursement decisions made by the NHIA for different nonreimbursement code categories. Further, related Pharmaceutical Benefit Reimbursement Scheme meeting minutes were analyzed to obtain more detailed information concerning medical devices' reimbursement or not. RESULTS: From December 2012 to June 2021, the overall reimbursement percentage was 56.7%, and the average amount of time between application and reimbursement was 856.7 ± 474.7 days. The mandatory reimbursement rate was about 45%. NHIA reimbursement decisions as special medical devices also take a longer amount of time, because the applicants need to agree to the decision (P < .05). The NHIA decision-making process for nonreimbursement medical devices requires a significantly longer amount of time than for general materials (eg, suture, etc) decisions. CONCLUSIONS: Although the Regulation resolves payment issues, it also increases the amount of time to reach reimbursement decisions, thus hindering patient access to innovative medical devices. The study suggests that the review process needs to be simplified concerning reimbursement notification, using local real-world data to support reimbursement decisions.

[Differences in Billing Patterns Between GPs and Pediatricians Using Early Diagnostics in Children and Adolescents as an Example: Analysis of Nationwide Data from Statutory Health Insurance Physicians]. / Kompensation von Leistungen zwischen Hausärzten und Kinder- und Jugendmedizinern am Beispiel der Früherkennungsuntersuchungen bei Kindern und Jugendlichen ­ Analyse von bundesweiten KBV-Daten.

BACKGROUND: Despite a 13.1% increase in the number of pediatricians between 2011 - 2020, the capacity of pediatric care has largely stagnated. This is due to increasing flexibility in working hours and a declining willingness of doctors to establish practices. In addition, there is an imbalance in the distribution of pediatric medical care capacities. While metropolitan areas are often characterized by oversupply, there is an increasing shortage of pediatricians, especially in rural areas. As a result, general practitioners in rural areas are increasingly taking over part of pediatric care. We quantify this compensation effect using the example of examinations of general health and normal child development (U1-U9). METHODS: Basis of the analysis was the Doctors' Fee Scale within the Statutory Health Insurance Scheme (Einheitlicher Bewertungsmaßstab, EBM) from 2015 (4th quarter). Nationwide data from the National Association of Statutory Health Insurance Physicians (KBV) for general practitioners and pediatricians from 2015 was evaluated. In the first step, the EBM was used to determine the potential overlap of services between the two groups of doctors. The actual compensation between the groups was quantified using general health and normal child development as an example. RESULTS: In section 1.7.1 (early detection of diseases in children) of the EBM, there is a list of 16 options for services that can be billed (fee schedule positions, GOP) by general practitioners and pediatricians. This particularly includes child examinations U1 to U9. The analysis of the national data of the KBV for the early detection of diseases in children showed significant differences between rural and urban regions in the billing procedure. Nationwide, general practitioners billed 6.6% of the services in the area of early detection of diseases in children in 2015. In rural regions this share was 23% compared to 3.6% in urban regions. The analysis of the nationwide data showed that the proportion of services billed by general practitioners was higher in rural regions than in urban regions. CONCLUSION: The EBM allows billing of services by both general practitioners and pediatricians, especially in the area of general GOP across all medical groups. The national billing data of the KBV shows that general practitioners in rural regions bill more services from the corresponding sections than in urban regions.

The economic cost of not coding disease-related malnutrition: A study in cancer inpatients.

BACKGROUND & AIMS: Disease-related malnutrition (DRM) coding rate is usually low in hospitalised patients. The objective of our study was to estimate the percentage of correct DRM coding in cancer inpatients and to calculate the economic losses caused by such lack of coding. METHODS: This was an observational, prospective study that was conducted in patients hospitalised in the Medical Oncology Unit of our hospital. A nutritional assessment was performed through subjective global assessment (SGA). The all patient refined-diagnosis related group (APR-DRG) weights were obtained at the moment of discharge; moreover, recalculation was done after including the diagnosis of malnutrition in the medical record of those patients in whom it had not been initially coded. The associated cost reimbursement were calculated based on the weight before and after revising the diagnosis of DRM. RESULTS: A total of 266 patients were evaluated. From them, 220 (82.7%) suffered from DRM according to the SGA. In 137 (51.5%) of these patients, diagnosis was coded, as opposed to 83 (31.2%) cases (33 subjects with moderate and 50 with severe DRM) in whom it was not coded. The sum of the APR-DRG weights before revising the diagnosis of malnutrition was 343.4 points (mean: 1.29 ± 0.89). Whereas, after revising the diagnosis, it increased up to 384.3 (1.44 ± 0.96). The total cost reimbursement for the hospital before revising the diagnosis of malnutrition was 1,607,861.21€ and after revision it increased up to 1,799,199.69€, which means that 191,338.48€ were not reimbursed to the hospital due to the lack of coding of malnutrition. The cost reimbursement for each admission increased an average of 719.32€. CONCLUSION: The prevalence of DRM in cancer inpatients is high. Nevertheless, the diagnosis is not coded in one third of patients, which results in important economic losses for the hospitals.

The impact of expanding health insurance coverage for anti-cancer drugs on cancer survival in Korea.

BACKGROUND: To reduce out-of-pocket costs, the Korean government expanded health insurance reimbursement in anti-cancer drugs for cancer patients in 2013. Our objective was to examine the impact of the benefit coverage expansion policy on healthcare utilization and overall survival (OS) among patients with six types of solid cancer after the policy of expanding health insurance coverage. METHODS: This study analyzed a before-and-after retrospective cohort of patients newly diagnosed with six types of solid cancer (stomach cancer, colorectal cancer, lung cancer, liver cancer, breast cancer, and prostate cancer) from January 1, 2009 to December 31, 2015 in Korea. The intervention was the expansion of reimbursement in 2013. Multivariate Cox proportional hazards regression was used to estimate the policy effect. RESULTS: In total, 142,579 before and 147,760 patients after the benefit expansion, and after matched by age, gender, and stage, 132,440 before and 132,440 patients after policy were included in the analysis. Almost total medical expenditure increased for five types of cancer increased. The expansion of health insurance reimbursement was associated with significantly lower overall mortality compared with pre-policy mortality for all six cancer sites. CONCLUSION: The policy of expanding health insurance reimbursement might have been associated with a significant increase in survival among cancer patients by ensuring access to health care and medicine. Although the reimbursement expansion timing differs for each cancer, it is believed that eliminating delayed treatment might rather lead to reduce medical expenses and improve health outcomes.

Young Adult Populations Face Yet Another Barrier to Care With Insurers: Limited Access to Proton Therapy.

PURPOSE: Young patients, including pediatric, adolescent, and young adult (YA) patients, are most likely to benefit from the reduced integral dose of proton beam radiation therapy (PBT) resulting in fewer late toxicities and secondary malignancies. This study sought to examine insurance approval and appeal outcomes for PBT among YA patients compared with pediatric patients at a large-volume proton therapy center. METHODS AND MATERIALS: We performed a cross-sectional cohort study of 284 consecutive patients aged 0 to 39 years for whom PBT was recommended in 2018 through 2019. Pediatric patients were defined as aged 0 to 18 years and YA patients 19 to 39 years. Rates of approval, denials, and decision timelines were calculated. Tumor type and location were also evaluated as factors that may influence insurance decisions. RESULTS: A total of 207 patients (73%) were approved for PBT at initial request. YA patients (n = 68/143, 48%) were significantly less likely to receive initial approval compared with pediatric patients (n = 139/141; 99%) (P < .001). Even after 47% (n = 35 of 75) of the PBT denials for YA patients were overturned, YAs had a significantly lower final PBT approval (72% vs pediatric 99%; P < .001). The median wait time was also significantly longer for YA patients (median, 8 days; interquartile range [IQR] 3-17 vs median, 2 days; IQR, 0-6; P < .001). In those patients requiring an appeal, the median wait time was 16 days (IQR, 9-25). CONCLUSION: Given the decades of survivorship of YA patients, PBT is an important tool to reduce late toxicities and secondary malignancies. Compared with pediatric patients, YA patients are significantly less likely to receive insurance approval for PBT. Insurance denials and subsequent appeal requests result in significant delays for YA patients. Insurers need to re-examine their policies to include expedited decisions and appeals and removal of arbitrary age cutoffs so that YA patients can gain easier access to PBT. Furthermore, consensus guidelines encouraging greater PBT access for YA may be warranted from both medical societies and/or AYA experts.

Medical claims paid by workers' compensation insurance among US Medicare beneficiaries, 1999-2016.

BACKGROUND: Workers' compensation claims among Medicare beneficiaries have not been described previously. To examine the healthcare burden of work-related injury and illness among Medicare beneficiaries, we assessed the characteristics, healthcare utilization, and financial costs among Medicare beneficiaries with claims for which workers' compensation was the primary payer. METHODS: We extracted final action fee-for-service Medicare claims from 1999 to 2016 where workers' compensation had primary responsibility for claim payment and beneficiary, claim type, diagnoses, and cost information from these claims. RESULTS: During 1999-2016, workers' compensation was the primary payer for 2,010,200 claims among 330,491 Medicare beneficiaries, and 58.7% of these beneficiaries had more than one claim. Carrier claims submitted by noninstitutional providers constituted the majority (94.5%) of claims. Diagnosis codes indicated 19.4% of claims were related to diseases of the musculoskeletal system and connective tissue and 12.9% were related to disease of the circulatory system. Workers' compensation insurance paid $880.4 million for these claims while Medicare paid $269.7 million and beneficiaries paid $37.4 million. CONCLUSIONS: Workers' compensation paid 74% of the total amount to providers for these work-related medical claims among Medicare beneficiaries. Claim diagnoses were similar to those of all workers' compensation claims in the United States. Describing these work-related claims helps identify the healthcare burden due to occupational injury and illness among Medicare beneficiaries resulting from employment and identifies a need for more comprehensive collection and surveillance of work-related medical claims.

Use of Standardized History and Physical Examination for Neurosurgical Patients Improves Clinical Documentation and Reimbursement.

BACKGROUND: Documentation is the cornerstone of good patient care and vital to proper coding and billing. Consistent and standardized documentation improves communication among physicians and can lead to better reimbursement. By understanding which elements in the neurosurgery history and physical examination are omitted the most often and the effects on the coding level, institutional-specific solutions can be implemented. METHODS: We performed a retrospective study of neurosurgical patients at a single academic institution who undergone a neurosurgery history and physical examination for an initial inpatient admission from July 2015 to July 2016. The data collected included documentation type (typed, dictated, dynamic documentation without a template, neurosurgery history and physical examination template [NHPT]) and ultimate coding level (1, 2, or 3) determined by a review by a professional coder. RESULTS: A total of 609 notes were reviewed. Of the 609 notes, 88 (14.4%) were missing an element of documentation. The most common missing element was the physical examination (40 of 88; 45.5%), followed by a combination (27 of 88; 30.7%), review of systems (14 of 88; 15.9%), and medical, family, and/or social history (7 of 88; 8.0%). The dynamic documentation without template notes had the highest percentage of missing elements (49 of 96; 51.0%), followed by the typed notes (7 of 49; 14.3%) and dictated notes (30 of 268; 11.2%) compared with the NHPT notes (2 of 196; 1.0%). CONCLUSION: The most common missing elements for inpatient neurosurgery documentation were the review of systems and physical examination. The documents with the highest percentage of missing elements were those that used dynamic documentation without a template. We recommend implementing a dedicated NHPT to improve capturing these elements for improved clinical documentation. Such changes could also improve the coding level and subsequent reimbursement.

Identifying outlier patterns of inconsistent ambulance billing in Medicare.

OBJECTIVE: To illustrate a method that accounts for sampling variation in identifying suppliers and counties with outlying rates of a particular pattern of inconsistent billing for ambulance services to Medicare. DATA SOURCES: US Medicare claims for a 20% simple random sample of 2010-2014 fee-for-service beneficiaries. STUDY DESIGN: We identified instances in which ambulance suppliers billed Medicare for transporting a patient to a hospital, but no corresponding hospital visit appeared in billing claims. We estimated the distributions of outlier supplier and county rates of such "ghost rides" by fitting a nonparametric empirical Bayes model with flexible distributional assumptions to account for sampling variation. DATA COLLECTION: We included Basic and advanced life support ground emergency ambulance claims with a hospital destination. PRINCIPAL FINDINGS: "Ghost ride" rates varied considerably across both ambulance suppliers and counties. We estimated 6.1% of suppliers and 5.0% of counties had rates that exceeded 3.6%, which was twice the national average of "ghost rides" (1.8% of all ambulance transports). CONCLUSIONS: Health care fraud and abuse are frequently asserted but can be difficult to detect. Our data-driven approach may be a useful starting point for further investigation.