Download or read book A Predictive Model Analyses of Medicare and Medicaid Inpatient Stays and the Role of Recovery Audit Contracting Program RAC written by Kathleen M. Kirk and published by . This book was released on 2017 with total page 105 pages. Available in PDF, EPUB and Kindle. Book excerpt: Advances in information acquisition techniques and the widespread use of information technologies in healthcare services has resulted in an incredible opportunity for health administrators to utilize data analytics and models to provide better health care, manage risks and improve patient outcomes. In this study two different data analytical models - a Logic Model and a Predictive Model - were formulated using data sets obtained from the Health Cost Utilization Project (HCUP) and the Recovery Audit Contractor (RAC) reports for use in Medicare and Medicaid patient hospitalization outcomes research. Objectives: The overall goal of the study was to (1) to design an appropriate analytical model to explain the operations of the RAC process and identify the hospitalization factors that affect the efficient recovery of claims (2) to formulate a predictive model by using HCUP's Nationwide Inpatient Sample datasets to help predict those hospitalization factors above affecting the RAC claims recovery process, and (3) to determine other relevant hospital, regional and patient related variables that play a statistically significant role in both the RAC and the Hospitalization Outcomes Models. Methods: To meet the aforementioned objectives data was extracted from both the RACTrac Website and Reports (for developing the RAC Process Model) and the HCUP Nationwide Inpatient Sample (NIS) database. Several analytical models currently in vogue in both health and finance were investigated and it was decided to adopt a Logic Model to describe the RAC claims recovery process and with its help identified the hospitalization factors related to the claims and payment issues. Secondly the Multiple Linear Regression Model was found to be the most suitable predictive model type for the 6 hospitalization factors identified from the RAC Logic Model. Lastly several descriptive and inferential statistics were employed to infer relationships among several patient and hospital variables with the RAC regions and their outcomes. Results: Both Length of Stay (LOS) and Total Charges were found to be intimately related to the RAC claims recovery process and accordingly they both were employed in the development of the Multiple Linear Regression Model with several independent variables such as DRG, RAC region, Payer type (Medicare, Medicaid, Private), Number of Diagnoses and Number of Procedures resulted in a reasonably good fit (54 % to 59 %) of the model in explaining the variance of the outcome of Total Charges and not a very good fit for the LOS which was expected since LOS is not a linear variable and subject to too many constraints and hence not easily predictable. The ANOVA Tests revealed several interesting relationships between the independent variables listed above and the RAC regions with implications of import for the RAC claims recovery process. Conclusion: This study is significant because it demonstrates the validity of the use of analytical models such as Logic Model and the Multiple Linear Regression Model in predicting Hospitalization Outcomes of interest to not only the RAC claims recovery process relevant to this study but also in other health administrative settings involving planning of budget and resource allocation. The complex process of RAC claims recovery mechanism has been duly modeled by the Logic Model technique thus making it available for future configuration modification and studies into their effect on theclaims recovery process.
Download or read book Program Integrity written by United States. Congress. Senate. Committee on Finance and published by . This book was released on 2013 with total page 80 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book Analyses for the Initial Implementation of the Inpatient Rehabilitation Facility Prospective Payment System written by Grace M. Carter and published by RAND Corporation. This book was released on 2002 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: This report describes the research that Rand performed to support the efforts of the Health Care Financing Adinnistration to design, develop, and implement a Prospective Payment System.
Download or read book Analyses for the Initial Implementation of the Inpatient Rehabilitation Facility Prospective Payment System written by and published by . This book was released on 2002 with total page 338 pages. Available in PDF, EPUB and Kindle. Book excerpt: In the Balanced Budget Act of 1997, Congress mandated that Health Care Financing Administration (HCFA) implement a Prospective Payment System (PPS) for inpatient rehabilitation. The Centers for Medicare and Medicaid Services (CMS, the successor agency to HCFA) issued the final rule governing such a PPS on August 7, 2001 and the system went into effect on January 1, 2002. This report details the analyses that RAND performed to support HCFA's efforts to design, develop, and implement the PPS. It describes RAND's research on new function-related groups, comorbidities, unusual cases, facility-level adjustments, outlier payments, facility-level adjustments, and assessment instruments. In addition, it presents RAND's recommendations concerning the payment system and discusses the researchers' plans for further research on the monitoring and refinement of the PPS.
Download or read book Fighting Fraud and Waste in Medicare and Medicaid written by United States. Congress. Senate. Committee on Appropriations. Subcommittee on Departments of Labor, Health and Human Services, Education, and Related Agencies and published by . This book was released on 2012 with total page 64 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book Medicare Primer written by Patricia A. Davis and published by . This book was released on 2016 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt: This report provides a general overview of the Medicare program including descriptions of the program's history, eligibility criteria, covered services, provider payment systems, and program administration and financing.
Download or read book Registries for Evaluating Patient Outcomes written by Agency for Healthcare Research and Quality/AHRQ and published by Government Printing Office. This book was released on 2014-04-01 with total page 385 pages. Available in PDF, EPUB and Kindle. Book excerpt: This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.
Download or read book Health Care Fraud and Abuse written by Aspen Health Law Center and published by . This book was released on 1998 with total page 156 pages. Available in PDF, EPUB and Kindle. Book excerpt: Stepped-up efforts to ferret out health care fraud have put every provider on the alert. The HHS, DOJ, state Medicaid Fraud Control Units, even the FBI is on the case -- and providers are in the hot seat! in this timely volume, you'll learn about the types of provider activities that fall under federal fraud and abuse prohibitions as defined in the Medicaid statute and Stark legislation. And you'll discover what goes into an effective corporate compliance program. With a growing number of restrictions, it's critical to know how you can and cannot conduct business and structure your relationships -- and what the consequences will be if you don't comply.
Download or read book Definition of Serious and Complex Medical Conditions written by Institute of Medicine and published by National Academies Press. This book was released on 1999-10-19 with total page 127 pages. Available in PDF, EPUB and Kindle. Book excerpt: In response to a request by the Health Care Financing Administration (HCFA), the Institute of Medicine proposed a study to examine definitions of serious or complex medical conditions and related issues. A seven-member committee was appointed to address these issues. Throughout the course of this study, the committee has been aware of the fact that the topic addressed by this report concerns one of the most critical issues confronting HCFA, health care plans and providers, and patients today. The Medicare+Choice regulations focus on the most vulnerable populations in need of medical care and other services-those with serious or complex medical conditions. Caring for these highly vulnerable populations poses a number of challenges. The committee believes, however, that the current state of clinical and research literature does not adequately address all of the challenges and issues relevant to the identification and care of these patients.
Download or read book Health Care Utilization as a Proxy in Disability Determination written by National Academies of Sciences, Engineering, and Medicine and published by National Academies Press. This book was released on 2018-04-02 with total page 161 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program. This report analyzes health care utilizations as they relate to impairment severity and SSA's definition of disability. Health Care Utilization as a Proxy in Disability Determination identifies types of utilizations that might be good proxies for "listing-level" severity; that is, what represents an impairment, or combination of impairments, that are severe enough to prevent a person from doing any gainful activity, regardless of age, education, or work experience.
Download or read book Improving the Quality of Care in Nursing Homes written by Institute of Medicine and published by National Academies Press. This book was released on 1986-02-01 with total page 432 pages. Available in PDF, EPUB and Kindle. Book excerpt: As more people live longer, the need for quality long-term care for the elderly will increase dramatically. This volume examines the current system of nursing home regulations, and proposes an overhaul to better provide for those confined to such facilities. It determines the need for regulations, and concludes that the present regulatory system is inadequate, stating that what is needed is not more regulation, but better regulation. This long-anticipated study provides a wealth of useful background information, in-depth study, and discussion for nursing home administrators, students, and teachers in the health care field; professionals involved in caring for the elderly; and geriatric specialists.
Download or read book Pay for Performance in Health Care written by Jerry Cromwell and published by RTI Press. This book was released on 2011-02-28 with total page 388 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book provides a balanced assessment of pay for performance (P4P), addressing both its promise and its shortcomings. P4P programs have become widespread in health care in just the past decade and have generated a great deal of enthusiasm in health policy circles and among legislators, despite limited evidence of their effectiveness. On a positive note, this movement has developed and tested many new types of health care payment systems and has stimulated much new thinking about how to improve quality of care and reduce the costs of health care. The current interest in P4P echoes earlier enthusiasms in health policy—such as those for capitation and managed care in the 1990s—that failed to live up to their early promise. The fate of P4P is not yet certain, but we can learn a number of lessons from experiences with P4P to date, and ways to improve the designs of P4P programs are becoming apparent. We anticipate that a “second generation” of P4P programs can now be developed that can have greater impact and be better integrated with other interventions to improve the quality of care and reduce costs.
Download or read book Developing a Protocol for Observational Comparative Effectiveness Research A User s Guide written by Agency for Health Care Research and Quality (U.S.) and published by Government Printing Office. This book was released on 2013-02-21 with total page 236 pages. Available in PDF, EPUB and Kindle. Book excerpt: This User’s Guide is a resource for investigators and stakeholders who develop and review observational comparative effectiveness research protocols. It explains how to (1) identify key considerations and best practices for research design; (2) build a protocol based on these standards and best practices; and (3) judge the adequacy and completeness of a protocol. Eleven chapters cover all aspects of research design, including: developing study objectives, defining and refining study questions, addressing the heterogeneity of treatment effect, characterizing exposure, selecting a comparator, defining and measuring outcomes, and identifying optimal data sources. Checklists of guidance and key considerations for protocols are provided at the end of each chapter. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews. More more information, please consult the Agency website: www.effectivehealthcare.ahrq.gov)
Download or read book Finding What Works in Health Care written by Institute of Medicine and published by National Academies Press. This book was released on 2011-07-20 with total page 267 pages. Available in PDF, EPUB and Kindle. Book excerpt: Healthcare decision makers in search of reliable information that compares health interventions increasingly turn to systematic reviews for the best summary of the evidence. Systematic reviews identify, select, assess, and synthesize the findings of similar but separate studies, and can help clarify what is known and not known about the potential benefits and harms of drugs, devices, and other healthcare services. Systematic reviews can be helpful for clinicians who want to integrate research findings into their daily practices, for patients to make well-informed choices about their own care, for professional medical societies and other organizations that develop clinical practice guidelines. Too often systematic reviews are of uncertain or poor quality. There are no universally accepted standards for developing systematic reviews leading to variability in how conflicts of interest and biases are handled, how evidence is appraised, and the overall scientific rigor of the process. In Finding What Works in Health Care the Institute of Medicine (IOM) recommends 21 standards for developing high-quality systematic reviews of comparative effectiveness research. The standards address the entire systematic review process from the initial steps of formulating the topic and building the review team to producing a detailed final report that synthesizes what the evidence shows and where knowledge gaps remain. Finding What Works in Health Care also proposes a framework for improving the quality of the science underpinning systematic reviews. This book will serve as a vital resource for both sponsors and producers of systematic reviews of comparative effectiveness research.
Download or read book Closing the Quality Gap written by Kaveh G. Shojania and published by . This book was released on 2004 with total page 7 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book Crossing the Quality Chasm written by Institute of Medicine and published by National Academies Press. This book was released on 2001-07-19 with total page 359 pages. Available in PDF, EPUB and Kindle. Book excerpt: Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America. Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers: A set of performance expectations for the 21st century health care system. A set of 10 new rules to guide patient-clinician relationships. A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality. Key steps to promote evidence-based practice and strengthen clinical information systems. Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.
Download or read book Report to the Congress Medicare Payment Policy written by Medicare Payment Advisory Commission (U.S.) and published by . This book was released on 1998 with total page 184 pages. Available in PDF, EPUB and Kindle. Book excerpt:
