Accession Number : ADA313821

Title :   Identifying Potential Bases for Bias in Medicare Part B.

Descriptive Note : Master's thesis,

Corporate Author : ACADEMY OF HEALTH SCIENCES (ARMY) FORT SAM HOUSTON TX HEALTH CARE ADMINISTRATI ON

Personal Author(s) : Bashford, Jeffrey A.

PDF Url : ADA313821

Report Date : 06 JUN 1995

Pagination or Media Count : 44

Abstract : One of the most difficult tasks facing Health Care Financing Administration policy makers is determining if medical necessity denial rates are appropriate for Medicare Part B claims. High or low rates are appropriate only if decisions are based solely on consistent application of valid criteria established by carriers for the purpose of identifying services that comply with the standards for medically necessary care. Although critics have been quick to find fault with the medical necessity review process, few have examined for systematic effects of this unfairness. The purpose of this study was to determine if there are trends in carrier medical review decisions, involving identifiable claims characteristics, that may indicate a basis for bias in claims processing. Claims reviewed for medical necessity by four regional carriers were analyzed for relationships between medical review decision and type of strategy for medical review; gender, origin of training and specialty of provider; place of service; and geographic location. While no relationship was found between medical review decision and type review, gender, origin, or place of service, both provider specialty and geographic location were significant predictors of review outcome.

Descriptors :   *CLINICAL MEDICINE, *MEDICAL SERVICES, *HEALTH CARE FACILITIES, *MEDICAL RESEARCH, POSITION(LOCATION), HIGH RATE, DECISION MAKING, STRATEGY, PREDICTIONS, PROCESSING, RATES, CONSISTENCY, MEDICINE, LOW RATE, GEOGRAPHY, AREA DENIAL.

Subject Categories : Medicine and Medical Research
      Medical Facilities, Equipment and Supplies

Distribution Statement : APPROVED FOR PUBLIC RELEASE