Insurance Claim Review

Publication Title: 
Inquiry: A Journal of Medical Care Organization, Provision and Financing

A majority of employees can choose among health insurance plans of varying generosity. They may switch plans if prices, information, or their health status change. This paper analyzes switching behavior presumptively caused by changes in health status. We show that people who move to a less generous plan have lower medical spending prior to the switch than the average for the generous plan in which they started, while those who move to a more generous plan appear to anticipate higher spending, which they delay until after the switch.

Author(s): 
Tchernis, Rusty
Normand, Sharon-Lise T.
Pakes, Juliana
Gaccione, Peter
Newhouse, Joseph P.
Publication Title: 
Psychiatric Services (Washington, D.C.)

OBJECTIVE: The 2003 Medicare Modernization Act shifted medication coverage from Medicaid to Medicare for persons dually eligible for both programs. This study examined the extent to which access to psychiatric and concomitant medications was reduced for dually eligible individuals in New York State. It also examined the extent to which consumer copayments and state costs were changed when the act was implemented in 2006.

Author(s): 
Jones, Kristine
Siegel, Carole
Bertollo, Dave N.
Samuels, Judith
Publication Title: 
Health Services Research

OBJECTIVE: To estimate patients' elasticity of demand, willingness to pay, and consumer surplus for five high-cost specialty medications treating metastatic disease or hematologic malignancies. DATA SOURCE/STUDY SETTING: Claims data from 71 private health plans from 1997 to 2005. STUDY DESIGN: This is a revealed preference analysis of the demand for specialty drugs among cancer patients. We exploit differences in plan generosity to examine how utilization of specialty oncology drugs varies with patient out-of-pocket costs.

Author(s): 
Goldman, Dana P.
Jena, Anupam B.
Lakdawalla, Darius N.
Malin, Jennifer L.
Malkin, Jesse D.
Sun, Eric
Publication Title: 
Health Services Research

OBJECTIVE: To analyze the effect of states' Medicaid bed-hold policies on the 30-day rehospitalization of Medicare postacute skilled nursing facility (SNF) residents. DATA SOURCES: Minimum data set assessments were merged with Medicare claims and eligibility files for all first-time SNF admissions (N = 3,322,088) over the period 2000 through 2005; states' Medicaid bed-hold policies were obtained via survey.

Author(s): 
Grabowski, David C.
Feng, Zhanlian
Intrator, Orna
Mor, Vincent
Publication Title: 
JAMA

CONTEXT: Implementation of Medicare Part D was followed by increased use of prescription medications, reduced out-of-pocket costs, and improved medication adherence. Its effects on nondrug medical spending remain unclear. OBJECTIVE: To assess differential changes in nondrug medical spending following the implementation of Part D for traditional Medicare beneficiaries with limited prior drug coverage.

Author(s): 
McWilliams, J. Michael
Zaslavsky, Alan M.
Huskamp, Haiden A.
Publication Title: 
Health Services Research

OBJECTIVES: To examine the effects of changes in payment and risk adjustment on (1) the annual enrollment and switching behavior of Medicare Advantage (MA) beneficiaries, and (2) the relative costliness of MA enrollees and disenrollees. DATA: From 1999 through 2008 national Medicare claims data from the 5 percent longitudinal sample of Parts A and B expenditures. STUDY DESIGN: Retrospective, fixed effects regression analysis of July enrollment and year-long switching into and out of MA.

Author(s): 
Morrisey, Michael A.
Kilgore, Meredith L.
Becker, David J.
Smith, Wilson
Delzell, Elizabeth
Publication Title: 
The American Journal of Managed Care

OBJECTIVES: Much has been written about trends in Medicare Part D formulary design and consumers' choice of plans, but little is known about the magnitude of claims rejections or their clinical and administrative implications. Our objective was to study the overall rate at which Part D claims are rejected, whether these rates differ across plans, drugs, and medication classes, and how these rejection rates and reasons have evolved over time.

Author(s): 
Stevenson, David G.
Keohane, Laura M.
Mitchell, Susan L.
Zarowitz, Barbara J.
Huskamp, Haiden A.
Publication Title: 
Medical Care

OBJECTIVE: We sought to assess how the inclusion of claims from complementary and alternative medicine (CAM) providers affects measures of morbidity burden and expectations of health care resource use for insured patients. METHODS: Claims data from Washington State were used to create 2 versions of a case-mix index. One version included claims from all provider types; the second version omitted claims from CAM providers who are covered under commercial insurance. Expected resource use was also calculated.

Author(s): 
Lind, Bonnie K.
Abrams, Chad
Lafferty, William E.
Diehr, Paula K.
Grembowski, David E.
Publication Title: 
The American Journal of Managed Care

OBJECTIVE: To assess the use of complementary and alternative medicine (CAM) providers and the associated expenditures by specific treatment phases among patients with cancer. STUDY DESIGN: Cross-sectional analysis of medical services utilization and expenditures during the 3 therapeutic phases of initial, continuing, and end-of-life life treatment. METHODS: Analysis of an insurance claims database that had been matched to the Washington State Surveillance, Epidemiology, and End Results cancer registry.

Author(s): 
Lafferty, William E.
Tyree, Patrick T.
Devlin, Sean M.
Andersen, M. Robyn
Diehr, Paula K.
Publication Title: 
Journal of Women's Health (2002)

BACKGROUND: Women with ovarian cancer have reported abdominal/pelvic pain, bloating, difficulty eating or feeling full quickly, and urinary frequency/urgency prior to diagnosis. We explored these findings in a general population using a dataset of insured women aged 40-64 and investigated the potential effectiveness of a routine review of claims data as a prescreen to identify women at high risk for ovarian cancer.

Author(s): 
Devlin, Sean M.
Diehr, Paula H.
Andersen, M. Robyn
Goff, Barbara A.
Tyree, Patrick T.
Lafferty, William E.

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