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BackgroundAnalyzing real-world data, including health insurance claims, may help provide insights into preventing and treating various diseases. We developed a database covering Shizuoka Prefecture (Shizuoka Kokuho Database [SKDB]) in Japan, which included individual-level linked data on health- and care-insurance claims and health checkup results.MethodsAnonymized claims data on health insurance (National Health Insurance [age

Background: Many women with endometriosis experience chronic abdominal pain. Clinical guidelines recommend treatment with analgesics, contraceptive hormones, gonadotropin-releasing hormone analogs,...

This study investigates the Asymmetric Information Management (AIM) technique's ability to detect fraudulent insurance claims submitted online. The AIM instructions inform claimants that, inter alia, more detailed statements are easier to accurately classify as genuine or fabricated. To test this, truth tellers (n=55) provided an honest statement about a lost or stolen item, while liars (n=53) provided a false claim. All claimants were randomly assigned to either receive the control or AIM instructions. We found that truth tellers provided more information in the AIM condition (compared to the control condition), and discriminant analysis classificatory performance was improved slightly. Unfortunately, the AIM instructions had little effect on the amount of information liars provided. Thus, the AIM technique is useful for supporting truth tellers to be more detailed, but more work needs to be conducted to assess why liars in this study did not adapt a withholding strategy.

Leveraging the increasing availability of ”big data” to inform forecasts of labor market activity is an active, yet challenging, area of research. Often, the primary difficulty is finding credible ways with which to consistently identify key elasticities necessary for prediction. To illustrate, we utilize a state-level event-study focused on the costliest hurricanes to hit the U.S. mainland since 2004 in order to estimate the elasticity of initial unemployment insurance (UI) claims with respect to search intensity, as measured by Google Trends. We show that our hurricane-driven Google Trends elasticity leads to superior real-time forecasts of initial UI claims relative to other commonly used models. Our approach is also amenable to forecasting both at the state and national levels, and is shown to be well-calibrated in its assessment of the level of uncertainty for its out-of-sample predictions during the Covid-19 pandemic.

Background: Mumps deafness causes serious problems, and incidence data are needed to identify its disease burden. However, such data are limited, and the reported incidence is highly variable. Nationwide studies in Japan with a large age range are lacking. Methods: This was a retrospective observational investigation of the 2005–2017 mumps burden using employment-based health insurance claims data. Data were analyzed for 5,190,326 people aged 0–64 years to estimate the incidence of mumps deafness. Results: Of 68,112 patients with mumps (36,423 males; 31,689 females), 102 (48 males; 54 females) developed mumps deafness—an incidence of 15.0 per 10,000 patients (1 in 668 patients). Fifty-four (52.9%) patients had mumps deafness in childhood (0–15 years), and 48 (47.1%) had mumps deafness in adolescence and adulthood (16–64 years); most cases occurred in childhood, the peak period for mumps onset. The incidence of mumps deafness per 10,000 patients was 73.6 in adolescence and adulthood, 8.4 times higher than the incidence of 8.8 in childhood (P < 0.001). In childhood, the incidence of mumps deafness was 7.2 times higher among 6–15-year-olds (13.8; 95% CI, 10.2–18.2) than among 0–5-year-olds (1.9; 95% CI, 0.6–4.5), and this difference was statistically significant (P < 0.001). No sex difference was observed. Conclusions: The incidence of mumps deafness per 10,000 patients aged 0–64 years was 15.0 (1 in 668 patients). A secondary risk of deafness following mumps virus infection was identified not only for children, but also for adolescents and adults.

Fraud in healthcare insurance claims is one of the significant research challenges that affect the growth of the healthcare services. The healthcare frauds are happening through subscribers, companies and the providers. The development of a decision support is to automate the claim data from service provider and to offset the patient’s challenges. In this paper, a novel hybridized big data and statistical machine learning technique, named MapReduce based iterative support vector machine (MR-ISVM) that provide a set of sophisticated steps for the automatic detection of fraudulent claims in the health insurance databases. The experimental results have proven that the MR-ISVM classifier outperforms better in classification and detection than other support vector machine (SVM) kernel classifiers. From the results, a positive impact seen in declining the computational time on processing the healthcare insurance claims without compromising the classification accuracy is achieved. The proposed MR-ISVM classifier achieves 87.73% accuracy than the linear (75.3%) and radial basis function (79.98%).

No extensive studies have investigated current diagnosis and treatment trends of hypogonadism (HG) in adult men in the United States. Using a comprehensive commercial insurance database, we surveyed current trends in incidence, prevalence, and treatment of hypogonadism in the United States. We analyzed insurance claims data from 2008-2017 using the IBM MarketScan™ Commercial Claims and Encounters database for men ≥18. Overall, we estimated annual incidence at 16.1 cases per 100,000 person-years, with the highest incidence seen among men 35-44 years at 21.5 cases per 100,000 person-years (IRR 1.83; 95% CI 1.63, 2.06, p

PurposeUsing unique trade credit insurance data from China, we examine whether trade insurance claims are associated with audit efforts and audit quality.Design/methodology/approachThe paper is based on a sample of Chinese firms to study insurance claims of trade credit insurance that affects abnormal audit fees.FindingsIn this study, we find that firms with high insurance claims pay higher abnormal audit fees. Further, our findings indicate that firms with high insurance claims have a short audit report lag and tend to select local audit firms.Originality/valueTo the best of our knowledge, this is the first study to investigate the association between trade credit insurance claims and audit efforts. In addition, we contribute to the literature on the agency cost of abnormal audit fees.

Real-world data derived from observational studies, particularly from administrative health care and insurance claims databases, are increasingly being used to evaluate treatment effectiveness. To control for potential biases, a number of analytical techniques have been developed. However, the procedures used can be far from intuitive, and this along with other methodological issues can make it challenging to assess whether reported results are real or artefactual. This commentary summarizes some of the issues associated with evaluating treatment effectiveness in the real-world setting, at the same time highlighting the important role observational studies can play.

The purpose of this study is to evaluate how to optimize marine insurance claims as well as the appropriate procedures in the marine cargo insurance claim process and methods in preparing insurance claim documents into accurate and complete documents so that the insurance company that bears all losses is more optimal by the insurance claims. with the details of the calculation of the value of insurance claims that have been insured. This research is divided into three lines of thought, namely identification, and formulation of problems, analysis and discussion, and research results. Identify and formulate problems by identifying possible problems that occur during the claim submission process. Based on the results of this identification then formulate the problem to be discussed in the study. Analysis and discussion by conducting the process of analysis and discussion of the problems that occur through the literature and collecting the necessary data. the next step is a discussion of the problems faced by covering the procedures and stages of filing a claim, the method adopted, and the evaluation method used for optimizing insurance claims. This study uses a qualitative method approach and a descriptive design is used to explain the process, the sample is taken at the shipping company PT. ABC, the representation is expected to be given by this sample. After using descriptive data analysis, the research results obtained that the insurance claim process must pay attention to the person in charge of carrying out marine cargo insurance claims; Types of compensation that can be submitted in the insurance claim process; Requirements in the process of filing an insurance claim, and the evidence that must be prepared to file an insurance claim. In addition, the loss must be filed immediately considering the deadline for submitting an insurance claim. The essence of the claim for ship cargo is compensation paid by the losses borne by the insurer to repair the suffering of the insured from loss of property.

The risk of incurring financial losses from fraudulent claims is an issue concerning all insurance companies. The detection of such claims is not an easy task. Moreover, a number of old-school meth...

The article presents a collective risk model for the insurance claims. The objective is to estimate a premium, which is defined as a functional specified up to unknown parameters. For this purpose, the Bayesian methodology, which combines the prior knowledge about certain unknown parameters with the knowledge in the form of a random sample, has been adopted. The generalised Bregman loss function is considered. In effect, the results can be applied to numerous loss functions, including the square-error, LINEX, weighted square-error, Brown, entropy loss. Some uncertainty about a prior is assumed by a distorted band class of priors. The range of collective and Bayes premiums is calculated and posterior regret Γ-minimax premium as a robust procedure has been implemented. Two examples are provided to illustrate the issues considered - the first one with an unknown parameter of the Poisson distribution, and the second one with unknown parameters of distributions of the number and severity of claims.

Background Hypernatremia and liver injury are typical adverse effects of tolvaptan. Therefore, hospitalization and frequent monitoring of serum sodium concentration and liver function are necessary for tolvaptan initiation. We performed a cross-sectional survey to evaluate these situations. Research design and methods We employed the Japanese claims database, which contains data of patients aged < 75 years. Patients who were newly prescribed tolvaptan for fluid accumulation induced by chronic heart failure (FA-CHF) or liver cirrhosis (FA-LC) from January 2011 to June 2017 were included. We evaluated the hospitalization status and implementation of serum sodium and liver function tests in the evaluation period, based on the Japanese package insert. Results Of 1,173 patients, 347 and 117 were enrolled in FA-CHF and FA-LC groups, respectively. Among them, 10.7% (FA-CHF group) and 5.13% (FA-LC group) were prescribed tolvaptan without hospitalization. In the FA-CHF group, 11.0% and 17.6% did not undergo serum sodium and liver function tests even once in the evaluation period, respectively, compared with 12.0% and 12.8% in the FA-LC group. Conclusions Our results highlight the deviation from Japanese package insert recommendations. This approach can be applied to other drugs and provides important perspectives on pharmacovigilance research.

Background Electronic frailty indices (eFIs) are increasingly used to identify patients at risk for morbidity and mortality. Whether eFIs capture the spectrum of frailty change, including decline, stability, and improvement, is unknown. Methods In a nationwide retrospective birth cohort of U.S. Veterans, a validated eFI, including 31 health deficits, was calculated annually using medical record and insurance claims data (2002–2012). K-means clustering was used to assign patients into frailty trajectories measured 5 years prior to death. Results There were 214 250 veterans born between 1927 and 1934 (mean [SD] age at death = 79.4 [2.8] years, 99.2% male, 90.3% White) with an annual eFI in the 5 years before death. Nine frailty trajectories were identified. Those starting at nonfrail or prefrail had 2 stable trajectories (nonfrail to prefrail, n = 29 786 and stable prefrail, n = 28 499) and 2 rapidly increasing trajectories (prefrail to moderately frail, n = 28 244 and prefrail to severely frail, n = 22 596). Those who were mildly frail at baseline included 1 gradually increasing trajectory (mildly to moderately frail, n = 33 806) and 1 rapidly increasing trajectory (mildly to severely frail, n = 15 253). Trajectories that started at moderately or severely frail included 2 gradually increasing trajectories (moderately to severely frail, n = 27 662 and progressing severely frail, n = 14 478) and 1 recovering trajectory (moderately frail to mildly frail, n = 13 926). Conclusions Nine frailty trajectories, including 1 recovering trajectory, were identified in this cohort of older U.S. Veterans. Future work is needed to understand whether prevention and treatment strategies can improve frailty trajectories and contribute to compression of morbidity toward the end of life.

Purpose: Percutaneous nephrolithotomy (PCNL) has wide variability in the methods of renal access. In many centers, this is done as a separate nephrostomy procedure by interventional radiology, while other urologists gain initial access themselves during the PCNL. We aimed to characterize these trends to confirm the need for continued training in this aspect of PCNL. Methods: Using MarketScan insurance claims, we examined surgical volume for ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL), and PCNL during 2007-2017. For PCNL, current procedural terminology (CPT) codes were used to identify the provider performing the de novo renal access over time. We stratified postoperative outcomes for PCNL by provider type. Results: From 2007 to 2017, the annual proportion of PCNL procedures peaked at 4.5%, with a recent decline in 2016 and 2017 to 3.2%. URS steadily increased from 46.3% to 60.0% of procedures, and SWL mirrored that change with a decrease from 50.0% to 36.7%. Within 19,743 PCNLs, there was a notable increase from 12.8% to 32.3% in the number of procedures with urologists performing de novo renal access. Most cases (40.0%) still had a de novo access code assigned to a radiologist. Length-of-stay, readmission, transfusion, and secondary stone procedure rates were higher in the radiologist-gained access PCNLs. Conclusions: URS has surpassed SWL as the most common stone procedure. While the proportion of PCNLs has remained fairly stable over the last decade, urologists obtaining their own de novo access have increased substantially. Continued outreach efforts focused on urologist-obtained access may further increase this proportion and improve outcomes for PCNL.

In performing endoscopic retrograde cholangiopancreatography (ERCP), doctors should know the details of insurance claims. The fee of ERCP will be charged separately by the treatment fee and the material costs, and should be charged according to the insurance claims to avoid any disadvantages later. Insurance claims for ERCP are often changed, so doctors have to notice the changes and apply them. During the procedure, it is important to properly record the photograph as a basis, and to keep a good description of the procedure and materials used on the reading sheet. After the procedure, it is necessary to double check the prescription and verify that the insurance claim has been properly filed.

The medical images can be tampered with by attackers with a malevolent goal of hiding or creating multiple copies of lesions, resulting in wrong treatment, false insurance claim, defame public figu...

Implementation of a National Health Insurance (NHI) in South Africa requires a reliable, standardized health information system that supports Diagnosis-Related Groupers for reimbursements and resource management. We assessed the quality of inpatient health records, the availability of standard discharge summaries and coded clinical data and the congruence between inpatient health records and discharge summaries in public-sector hospitals to support the NHI implementation in terms of reimbursement and resource management. We undertook a cross-sectional health-records review from 45 representative public hospitals consisting of seven tertiary, 10 regional and 28 district hospitals in 10 NHI pilot districts representing all nine provinces. Data were abstracted from a randomly selected sample of 5795 inpatient health records from the surgical, medical, obstetrics and gynaecology, paediatrics and psychiatry departments. Quality was assessed for 10 pre-defined data elements relevant to NHI reimbursements, by comparing information in source registers, patient folders and discharge summaries for patients admitted in March and July 2015. Cohen's/Fleiss’ kappa coefficients (κ) were used to measure agreements between the sources. While 3768 (65%) of the 5795 inpatient-level records contained a discharge summary, less than 835 (15%) of diagnoses were coded using ICD-10 codes. Despite most of the records having correct patient identifiers [κ: 0.92; 95% confidence interval (CI) 0.91–0.93], significant inconsistencies were observed between the registers, patient folders and discharge summaries for some data elements: attending physician’s signature (κ: 0.71; 95% CI 0.67–0.75); results of the investigation (κ: 0.71; 95% CI 0.69–0.74); patient’s age (κ: 0.72; 95% CI 0.70–0.74); and discharge diagnosis (κ: 0.92; 95% CI 0.90–0.94). The strength of agreement for all elements was statistically significant (P-value ≤ 0.001). The absence of coded inpatient diagnoses and identified data inaccuracies indicates that existing routine health information systems in public-sector hospitals in the NHI pilot districts are not yet able to sufficiently support reimbursements and resource management. Institutional capacity is needed to undertake diagnostic coding, improve data quality and ensure that a standard discharge summary is completed for every inpatient.

There is substantial interest in using urgent care centers to decrease lower-acuity emergency department (ED) visits. Using 2008-19 insurance claims and enrollment data from a national managed care plan, we examined the association within ZIP codes between changes in rates of urgent care center visits and rates of lower-acuity ED visits. We found that although the entry of urgent care deterred lower-acuity ED visits, the impact was small. We estimate that thirty-seven additional urgent care center visits were associated with a reduction of a single lower-acuity ED visit. In addition, each $1,646 lower-acuity ED visit prevented was offset by a $6,327 increase in urgent care center costs. Therefore, despite a tenfold higher price per visit for EDs compared with urgent care centers, use of the centers increased net overall spending on lower-acuity care at EDs and urgent care centers.

The development and application of computational data mining techniques in financial fraud detection and business failure prediction has become a popular cross-disciplinary research area in recent times involving financial economists, forensic accountants and computational modellers. Some of the computational techniques popularly used in the context of - financial fraud detection and business failure prediction can also be effectively applied in the detection of fraudulent insurance claims and therefore, can be of immense practical value to the insurance industry. We provide a comparative analysis of prediction performance of a battery of data mining techniques using real-life automotive insurance fraud data. While the data we have used in our paper is US-based, the computational techniques we have tested can be adapted and generally applied to detect similar insurance frauds in other countries as well where an organized automotive insurance industry exists.

PURPOSE: To determine if metformin is associated with non-infectious uveitis (NIU). METHODS: Patients in an insurance claims database who initiated metformin (n=359,139) or other oral anti-diabetic medications (n=162,847) were followed for NIU development. Both cohort and case-control analyses were performed to assess differing exposure lengths using Cox and conditional logistic regression, respectively. RESULTS: The hazard ratio (HR) for incident NIU was not significantly different between the metformin and non-metformin cohorts [HR=1.19, 95% Confidence Interval (CI): 0.92-1.54, P=0.19]. The case-control analysis similarly showed no association between any metformin use 2 years before the outcome date and NIU [Odds ratio (OR)=0.64, 95% CI: 0.39-1.04, P=0.07]. However, there was a protective association between cumulative metformin duration [445-729 days adjusted OR (aOR)=0.49, 95% CI: 0.27-0.90, P=0.02) and dosage (>390,000 mg aOR=0.44, 95% CI: 0.25-0.78, P=0.001] compared with no metformin use. CONCLUSIONS: Our results suggest metformin use for longer durations may be protective of NIU onset.

This study aims to calculate the allowance for losses by applying Gaussian Process regression to estimate future claims. Modeling is done on motor vehicle insurance data. The data used in this study are historical data on PT XYZ's motor vehicle insurance business line during 2017 and 2019 (January 2017 to December 2019). Data analysis will be carried out on the 2017 - 2019 data to obtain an estimate of the claim reserves in the following year, namely 2018 - 2020. This study uses the Chain Ladder method which is the most popular loss reserving method in theory and practice. The estimation results show that the Gaussian Process Regression method is very flexible and can be applied without much adjustment. These results were also compared with the Chain Ladder method. Estimated claim reserves for PT XYZ's motor vehicle business line using the chain-ladder method, the company must provide funds for 2017 of 8,997,979,222 IDR in 2018 16,194,503,605 IDR in 2019 amounting to Rp. 1,719,764,520 for backup. Meanwhile, by using the Bayessian Gaussian Process method, the company must provide funds for 2017 of 9,060,965,077 IDR in 2018 amounting to 16,307,865,130 IDR, and in 2019 1,731,802,871 IDR for backup. The more conservative Bayessian Gaussian Process method. Motor vehicle insurance data has a short development time (claims occur) so that it is included in the short-tail type of business.

The distribution of out-of-pocket spending throughout the year is an important determinant of health care affordability that has received little attention. We used 2017 data from a large database of US commercial insurance claims to study the distribution of patient-level out-of-pocket spending throughout the year, highlighting potential hardship due to temporal clustering of spending. We found that although most commercially insured people had several health care encounters throughout the year, their out-of-pocket spending was mostly concentrated within short time intervals. Nearly one-third of people with above-the-median total annual health care spending (plan plus out-of-pocket spending) incurred half of their annual out-of-pocket spending in just one day. Policy makers working to improve the affordability of care should focus on innovative approaches to cost sharing that prevent dramatic financial shocks to household budgets due to medical bills.

Background The objective of this study was to evaluate factors associated with postoperative opioid use after open treatment of distal radius fractures. Methods The Humana insurance claims database was queried for open treatment of distal radius fractures by Current Procedural Terminology codes. The search was further refined to identify patients who filled an opioid prescription within 6 weeks after their surgery. The study’s outcomes were: (1) limited postoperative opioid use, defined as filling a prescription once in the 6-week to 6-month period after surgery; and (2) persistent postoperative opioid use, defined as filling a prescription more than once in the 6-week to 6-month period after surgery. Logistic regression models were performed to identify factors associated with limited and persistent postoperative opioid use. Subgroup analyses were performed among opioid-naïve patients and those with open fractures. Results This study identified 9141 of 19 220 total patients with limited and persistent opioid use. Significant risk factors included nonhome discharge, inpatient surgical setting, long-term pain, tobacco abuse, and age less than 65 years. Of note, both preoperative opioid use within 1 month before surgery (odds ratio [OR], 2.6; 95% confidence interval [CI], 2.2-2.9) and preoperative opioid use between 1 and 6 months before surgery (OR, 4.0; 95% CI, 3.7-4.4) were significantly associated with persistent postoperative opioid use. Conclusions This study has identified numerous risk factors associated with postoperative opioid use after open treatment of distal radius fractures. Understanding these risk factors is the first step toward reducing postoperative opioid use.

From the early days of the first national lockdown in England, widespread concerns over many different types of insurance claims had been raised. The business interruption losses that the small bus...

In 2018 New Jersey implemented a final-offer arbitration system to resolve payment disputes between insurers and out-of-network providers over surprise medical bills. Similar proposals are being considered by Congress and other states. In this article we examine how arbitration decisions compare with other relevant provider payment amounts by linking administrative data from New Jersey arbitration cases to Medicare and commercial insurance claims data. We find that decisions track closely with one of the metrics that arbitrators are shown-the eightieth percentile of provider charges-with the median decision being 5.7 times prevailing in-network rates for the same services. It is not a foregone conclusion that arbitrators will select winning offers based on proximity to this target, although our findings suggest that it is a strong anchor. The amount that providers can expect to receive through the arbitration process also affects their bargaining leverage with insurers, which could affect in-network negotiated rates more broadly. Therefore, basing arbitration decisions or a payment standard on unilaterally set provider-billed charges appears likely to increase health care costs relative to other surprise billing solutions and perversely incentivizes providers to inflate their charges over time.

PURPOSE/AIM: To assess whether ocular antihypertensives are associated with development and progression of age-related macular degeneration (AMD). MATERIALS AND METHODS: This retrospective, observational cohort study using healthcare claims data from a U.S. nationwide managed-care network between January 1, 2006 and December 31, 2016 included enrollees ≥40 years old with primary open angle glaucoma with or without a diagnosis of nonexudative AMD at the index date. Hazard ratios (HR) for developing AMD or progressing from nonexudative to exudative AMD with exposure to ocular antihypertensive medications were analyzed. RESULTS: Of 132 963 eligible enrollees, 118 174 (87.5%) had no diagnosis of AMD at baseline while 14 789 (12.5%) had a diagnosis of nonexudative AMD. Prostaglandin analog exposure had a decreased hazard of developing AMD among individuals without baseline disease (HR, 0.90; 95% CI, 0.87–0.94; p

Multivariate claim data are common in insurance applications, for example, claims of each policyholder from different types of insurance coverages. Understanding the dependencies among such multivariate risks is critical to the solvency and profitability of insurers. Effectively modeling insurance claim data is challenging due to their special complexities. At the policyholder level, claim outcomes usually follow a two-part mixed distribution: a probability mass at zero corresponding to no claim and an otherwise positive claim from a skewed and long-tailed distribution. To simultaneously accommodate the complex features of the marginal distributions while flexibly quantifying the dependencies among multivariate claims, copula models are commonly used. Although a substantial body of literature focusing on copulas with continuous outcomes has emerged, some key steps do not carry over to mixed data. In particular, existing nonparametric copula estimators are not consistent for mixed data, and thus copula specification and diagnostics for mixed outcomes have been a problem. However, insurance is a closely regulated industry in which model validation is particularly important, and it is essential to develop a baseline nonparametric copula estimator to identify the underlying dependence structure. In this article, we fill in this gap by developing a nonparametric copula estimator for mixed data. We show the uniform convergence of the proposed nonparametric copula estimator. Through simulation studies, we demonstrate that the proportion of zeros plays a key role in the finite sample performance of the proposed estimator. Using the claim data from the Wisconsin Local Government Property Insurance Fund, we illustrate that our nonparametric copula estimator can assist analysts in identifying important features of the underlying dependence structure, revealing how different claims or risks are related to one another.

At Makassar City Hospital, one of the service indicators that has not been achieved is in incomplete medical record files and medical record files that are returned more than 2x24 hours after service. This study aims to analyze the implementation of the completeness of filling in and the timeliness of returning inpatient medical record files at the Makassar City Hospital. This type of research is mixed methods research. The study design used a cross-sectional approach. The study was conducted in September - October 2020. The results showed that the implementation of completeness of filling in and the timeliness of returning medical record files was still low, this has led to the accumulation of medical record files in the treatment room and delays in returning the files of inpatients to the medical record installation of the City Hospital Makassar. Training on the implementation of medical records has not been comprehensive for all officers at the Makassar City Hospital. The result of the delay in returning the documents is the delay in payment of insurance claims to the hospital. Accumulation of medical records in the treatment room from incomplete medical records and returned to the treatment room. Health workers who forget to fill in complete medical records are only given a sanction in the form of a warning during a meeting with the medical committee. Availability of SOP on filling and returning medical record files at the hospital. The facilities and infrastructure in the implementation of medical records are still insufficient for medical record employees at Makassar City Hospital. It is recommended that the hospital improve the implementation of the completeness and timeliness of returning medical record files, provide incentives or rewards for completing filling in, increase the number of computers and expand the room in the medical record installation, and review the medical record format at Makassar City Hospital

Although the incidence of major pediatric lower limb loss secondary to either congenital deficiencies or acquired amputations is relatively low, the prevalence of lower limb loss among children in the United States (US) remains unknown.To estimate the prevalence of major lower limb loss, and the associated prosthetic services use and costs among commercially-insured children in the US.Observational, retrospective, longitudinal cohort study.The IBM MarketScan®Commercial Database was used to identify children (18 years) with major lower limb loss in the US between 2009 and 2015. Descriptive statistics were used to characterize pediatric cases according to sociodemographic and limb loss characteristics. Multivariate models assessed factors associated with annual prosthetic visits, prosthetic-related costs, and overall medical costs.Of the 36.5 million children in the MarketScan database, 14,038 had a major lower limb loss, yielding a prevalence estimate of 38.5 cases per 100,000 commercially insured children in the US during the 7-year study period. Congenital deficiencies accounted for 84% of cases, followed by 13.5% from trauma. Only 10.1% had at least one prosthesis-related visit during any 12-month period following their cohort entry. Among those, the mean annual prosthetic-related costs ranged from $50 to $29,112 with a median annual cost of $2778 (interquartile range = $4567). Annual coinsurance and copays for prosthetic services accounted for nearly half of the overall annual out-of-pocket outlays with medical care for these children.Pediatric lower limb loss results in lifelong prosthetic needs. This study informs insurers and policy-makers regarding the prevalence of these patients and the medical costs for their care.

To characterize regional variation in the age of patients undergoing umbilical hernia repair to determine costs and subsequent care.We performed a cross-sectional descriptive study using a large convenience sample of US employer-based insurance claims from July 2012 to December 2015. We identified children younger than 18 years of age undergoing uncomplicated (not strangulated, incarcerated, or gangrenous) umbilical hernia repair as an isolated procedure (International Classification of Diseases, Ninth Revision procedure codes 53.41, 53.42, 53.43, or 53.49, International Classification of Diseases, Tenth Revision procedure code 0WQF0ZZ, or Current Procedural Terminology procedure codes 49580 or 49585).In all, 5212 children met criteria for inclusion. Children younger than age 2 years accounted for 9.7% of repairs, with significant variation by census region (6% to 14%, P .001). Total payments for surgery varied by age; children younger than 2 years averaged $8219 and payments for older children were $6137. Postoperative admissions occurred at a rate of 73.1 per 1000 for children younger than age 2 years and 7.43 for older children; emergency department visits were 41.5 per 1000 for children younger than age 2 years vs 15.9 for older children (P .001).Umbilical hernias continue to be repaired at early ages with large regional variation. Umbilical hernia repair younger than age 2 years is associated with greater costs and greater frequency of postoperative hospitalization and emergency department visits.

Vladimir Zah,1 Jovana Pelivanovic,1 Simona Tatovic,1 Djurdja Vukicevic,1 Martina Imro,1 Jane Ruby,2 David Hurley2 1Health Economics and Outcomes Research Department, ZRx Outcomes Research Inc., Mississauga, ON, Canada; 2Medical Affairs, Endo Pharmaceuticals Inc., Malvern, PA, USACorrespondence: Vladimir ZahZRx Outcomes Research Inc, Mississauga, ON, CanadaTel +1 416-953-4427Email vzah@outcomesresearch.caObjective: Studies examining differences in US healthcare resource utilization (HCRU) and associated healthcare costs between collagenase clostridium histolyticum (CCH) and fasciectomy for Dupuytren contracture (DC) are limited. This study evaluated US HCRU and direct healthcare cost for the treatment of DC in privately insured patients using insurance claims.Methods: This retrospective observational cohort study analyzed data from large nationwide insurance claims databases; it included individuals diagnosed with DC between July 1, 2011, and June 30, 2017, who were adults at index date (date of first treatment: CCH or fasciectomy). Participants had continuous health plan coverage 24 months pre-index and 12 months post-index date. All-cause and DC-related HCRU and healthcare costs from the payers’ perspective were compared between propensity score–matched cohorts. Generalized linear models assessed factors associated with all-cause total healthcare costs.Results: Of 83,983 patients diagnosed with DC, 1932 adults receiving fasciectomy and 953 adults receiving CCH were included. The mean ± standard deviation total all-cause healthcare cost was significantly lower with CCH than with fasciectomy (US$11,897 ± US$14,633 versus US$15,528 ± US$22,254, respectively; P< 0.001). After propensity score matching, 702 and 999 patients remained in the CCH and fasciectomy cohorts, respectively. In this analysis, all-cause and DC-related total costs were significantly lower in the CCH cohort versus the fasciectomy cohort (all-cause: US$11,044 ± US$12,856 versus US$12,912 ± US$19,237, respectively, P=0.02; DC-specific: US$3417 ± US$3671 versus US$5800 ± US$4985, P< 0.001), mainly due to the lower frequency of outpatient visits. CCH treatment and the use of a consumer-driven healthcare plan were associated with lower healthcare costs.Conclusion: Based on matched cohort data, adjusted 1-year healthcare costs for CCH-treated individuals were significantly lower compared with costs for fasciectomy-treated individuals.Keywords: injection, surgery, insurance claims, retrospective database study

Background Little is known about strategies for enrolling patients in home-based palliative care programs despite the need to conduct effectiveness studies of this emerging industry. Purpose We used medical claims data from Accountable Care Organizations in California to identify patients for a randomized controlled trial of home-based palliative care. We report outcomes from this strategy and the implications for future research. Results Claims data identified 1357 patients. Research assistants could not reach 986 patients (72.7%), usually because the phone calls went unanswered (38.5%) and many patients' phone numbers were missing or incorrect (16.3%). Of 371 patients reached, 163 opted out. Of 208 patients screened, 177 were ineligible for the trial. Just 10 patients were enrolled. Recommendations Our findings suggest that medical claims data may not be useful for engaging patients potentially eligible for palliative care research trials. We recommend that alternative identification and recruitment strategies be considered.

Problems commonly found in submitting insurance claims are incomplete documents, follow-up claims, the mismatch of the rates submitted by the hospital with the INA-CBGs rates or those paid by BPJS Kesehatan, irregularities in the coding of disease diagnoses, and the delay in claiming payments by BPJS Kesehatan. Based on the preliminary study at Soe Public Hospital in October 2019, there were still several administrative problems in submitting claims for JKN program. It was proven by the fact that there were still patients with JKN who did not bring a copy of their BPJS Kesehatan cards and the referral letter determined by BPJS Kesehatan when registering for a treatment. The aim of this study is to determine the factors causing the delay in submitting claims for inpatients with BPJS at Soe Public Hospital in 2020.This was a qualitative descriptive study. The population in this study was staff who are directly involved in the insurance claiming process. The sample was selected using purposive sampling technique that consisted of one assembling staff, one coding staff, two internal verifiers and one BPJS Kesehatan verifier. The results of the study indicated that the process of submitting claims for patients with BPJS Kesehatan by Soe Public Hospital did not carry out in a comprehensive and integrated manner because of incomplete medical record status, lack of coordination and teamwork between staff who record medical status that involves assembling staff, coding staff, and hospital verifier. This made a delay in submitting claims for inpatients with BPJS Kesehatan. There were also other obstacles found in the process of submitting claims for inpatients with BPJS Kesehatan at Soe Public Hospital. It is suggested that hospital managers need to evaluate staff who are responsible for submitting claims for inpatients with BPJS Kesehatan regularly and to assess the strengths and weaknesses of each staff.

Large administrative healthcare (including insurance claims) databases are used for various retrospective real-world evidence studies. However, in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension, identifying patients retrospectively based on administrative codes remains challenging, as it relies on code combinations (algorithms) and the accuracy for patient identification of most of them is unknown. This study aimed to assess the performance of various algorithms in correctly identifying patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension in administrative databases. A systematic literature review was performed to find publications detailing code-based algorithms used to identify pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension patients. PheValuator, a diagnostic predictive modelling tool, was applied to three US claims databases, yielding models that estimated the probability of a patient having the disease. These models were used to evaluate the performance characteristics of selected pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension algorithms. With increasing algorithm complexity, average positive predictive value increased (pulmonary arterial hypertension: 13.4-66.0%; chronic thromboembolic pulmonary hypertension: 10.3-75.1%) and average sensitivity decreased (pulmonary arterial hypertension: 61.5-2.7%; chronic thromboembolic pulmonary hypertension: 20.7-0.2%). Specificities and negative predictive values were high (≥97.5%) for all algorithms. Several of the algorithms performed well overall when considering all of these four performance parameters, and all algorithms performed with similar accuracy across the three claims databases studied, even though most were designed for patient identification in a specific database. Therefore, it is the objective of a study that will determine which algorithm may be most suitable; one- or two-component algorithms are most inclusive and three- or four-component algorithms identify most precise pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension populations, respectively.

This essay provides a reflective commentary outlining Hawai’i’s unconventional response for employing a volunteer workforce of public servants when faced with the task of processing an unprecedented backlog of unemployment insurance claims triggered by the COVID-19 pandemic. Although efforts are still ongoing, this essay applies volunteerism and public service motivation as a framework to explain why public servants would serve in a voluntary capacity at another public agency. The intent of this essay is to spur conversation on how public servants are further stepping up to the frontlines during times of crisis, as well as expand knowledge on the relationship between volunteerism and public service motivation.

Actuaries are often in search of finding an adequate model for actuarial and financial risk management problems. In the present work, we introduce a class of claim distributions useful in a number ...

Fourteen states and the District of Columbia allow unauthorized immigrants to obtain driver's licenses. Using variation in the timing and location of these policy changes, we show these Unauthorized Immigrant License Polices (UILPs) are associated with a 1% increase in both the number of licensed drivers and liability insurance coverage, although we do not document a statistically significant relationship with auto insurance claims. Nor do we detect a significant relationship between UILPs and the number of miles driven, vehicle registrations, air quality, or travel behaviors. Overall, our results are consistent with UILPs licensing unauthorized immigrants who were already driving. (JEL R48, G22, K37)

Tweedie's compound Poisson model is a popular method to model insurance claims with probability mass at zero and nonnegative, highly right-skewed distribution. In particular, it is not uncommon to have extremely unbalanced data with excessively large proportion of zero claims, and even traditional Tweedie model may not be satisfactory for fitting the data. In this paper, we propose a boosting-assisted zero-inflated Tweedie model, called EMTboost, that allows zero probability mass to exceed a traditional model. We makes a nonparametric assumption on its Tweedie model component, that unlike a linear model, is able to capture nonlinearities, discontinuities, and complex higher order interactions among predictors. A specialized Expectation-Maximization algorithm is developed that integrates a blockwise coordinate descent strategy and a gradient tree-boosting algorithm to estimate key model parameters. We use extensive simulation and data analysis on synthetic zero-inflated auto-insurance claim data to illustrate our method's prediction performance.

Flood-related water damages have become the largest home insurance claims in North America in recent years. In response, considerable effort is being focused on options to reduce flood damages, inc...

There is abundant literature on efforts to reduce opioid prescriptions and misuse, but comparatively little on the treatment provided to people with opioid use disorder (OUD). Using claims data rep...

While out-of-network or potential “surprise” billing has garnered increasing attention, particularly in emergency department and inpatient settings, few national studies have examined out-of-networ...

Despite progress in pharmacotherapy in pediatric pulmonary hypertension, real-world patterns of directed pulmonary hypertension therapy have not been studied in the current era. A retrospective observational study of children (≤18 years) with pulmonary hypertension was performed using data from the MarketScan® Commercial and Medicaid claims databases. Associations between etiology of pulmonary hypertension and pharmaceutical regimen were evaluated, as were the associations between subject social and geographic characteristics (insurance-type, race, and/or census region) and regimen. Annualized costs of single- and multi-class regimens were calculated. In total, 873 subjects were studied, of which 94% received phosphodiesterase-5 inhibitors, 31% endothelin receptor antagonist, 9% prostacyclin analogs, and 7% calcium channel blockers. Monotherapy was used in 72% of subjects. Phosphodiesterase-5 inhibitors monotherapy was the most common regimen (93%). Subjects with idiopathic pulmonary hypertension, congenital heart disease, and unclassified pulmonary hypertension receive more than one agent and were more likely to receive both endothelin receptor antagonist and prostacyclin analogs than other forms of pulmonary hypertension. Compared to recipients of public insurance, subjects with commercial insurance were more likely to receive more intense therapy ( p = 0.003), which was confirmed in multivariable analysis (OR: 1.4, p = 0.03). Receipt of commercial insurance was also associated with increased annual costs across all subjects ( p