Closure, fair procedures, and setting limits within managed care organizations

Article Abstract:

Managed care organizations (MCOs) should begin to include the reasons why they limit coverage for certain conditions. This information could be included in the letter to the physician or in support materials that are given to patients and their families. Most MCOs do not supply such reasons, but this has led to the suspicion that they limit coverage to improve profits. However, there could be scientific evidence for the decision and publicizing that information would improve the MCOs public image.

Information services, Managed care plans (Medical care)

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When the benefit is in doubt, who decides?

Article Abstract:

HMOs must ensure that their benefit coverage decisions are based on rules that are fair, objective and have the members' best interests in mind. Two occasions when benefit coverage is problematic is when a covered benefit is not necessary or appropriate for a specific patient or when a patient requests an experimental treatment. There is no single, organized system for making benefit coverage decisions or determining which treatments are experimental.

Planning, Contracts, Medical research, Health maintenance organizations, Medicine, Experimental

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Misclassification and selection bias when identifying Alzheimer's disease solely from Medicare claims records

Article Abstract:

Discrepancies and misclassified diagnoses may distort the true incidence of Alzheimer's disease according to Medicare claims records. Medicare claims referred by physicians represented a 68% rate of Alzheimer's disease, although the confirmed diagnosis by the Medicare Alzheimer's Disease Demonstration reached less than 20%. Health care expenses were higher than expected. This type of underclassification can be overcome by adjusting the claims period.

Diagnosis, Diagnostic errors, Surveys, Alzheimer's disease, Records and correspondence, Medicare

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