Dataset Information

Medicare Part D claims rejections for nursing home residents, 2006 to 2010.

ABSTRACT: 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.We performed descriptive analyses of data on paid and rejected Part D claims submitted by 1 large national longterm care pharmacy from 2006 to 2010. In each of the 5 study years, data included approximately 450,000 Medicare beneficiaries living in long-term care settings with approximately 4 million Part D drug claims. Claims rejection rates and reasons for rejection are tabulated for each study year at the plan, drug, and class levels.Nearly 1 in 6 drug claims was rejected during the first 5 years of the Medicare Part D program, and this rate has increased over time. Rejection rates and reasons for rejection varied substantially across drug products and Part D plans. Moreover, the reasons for denials evolved over our study period. Coverage has become less of a factor in claims rejections than it was initially and other formulary tools such as drug utilization review, quantity-related coverage limits, and prior authorization are increasingly used to deny claims.Examining claims rejection rates can provide important supplemental information to assess plans' generosity of coverage and to identify potential areas of concern.

SUBMITTER: Stevenson DG

PROVIDER: S-EPMC3540110 | biostudies-literature | 2012 Oct

REPOSITORIES: biostudies-literature

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Medicare Part D claims rejections for nursing home residents, 2006 to 2010.

Stevenson David G DG Keohane Laura M LM Mitchell Susan L SL Zarowitz Barbara J BJ Huskamp Haiden A HA

The American journal of managed care 20121001 10

<h4>Objectives</h4>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.<h4>Study design and methods</h4>We performed de ...[more]

PMID: 23145808

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Project description:ObjectiveTo assess the effects of eLongTermCare (eLTC), a telehealth program implemented by an integrated health system in 45 nursing homes across the Midwest, on the use of acute hospital services and total expenditures for Medicare residents.Data sourcesMinimum Data Set, Medicare fee-for-service claims, and enrollment data from 2013 to 2018.Study designWe used a longitudinal difference-in-differences design to estimate the changes in outcomes for treatment beneficiaries before and after participating in the eLTC program, relative to changes for the matched comparison beneficiaries over the same period. We measured outcomes over a 24-month follow-up period, including total Medicare spending, emergency department (ED) visits, hospitalizations, and the likelihood of readmission.Data collection/extraction methodsUsing administrative data, we identified treatment beneficiaries who stayed at participating nursing facilities during the program period and matched comparison beneficiaries with similar baseline characteristics from non-participating facilities in the same geographic locations.Principal findingsFor long-term care residents, the eLTC program led to an estimated reduction of 73 ED visits per 1000 beneficiaries (p < 0.01, 8.6% effect) over the two-year follow-up period. The estimated effects for this group were concentrated among beneficiaries who entered the nursing home after program startup, with sizable reductions in hospitalizations, ED visits, and spending. For skilled care residents, the program was associated with an estimated reduction of 85 ED visits per 1000 beneficiaries (p = 0.03, 9.7% effect), but had no discernible effect on their hospitalizations or total Medicare spending.ConclusionsTelehealth can be a valuable tool for nursing homes to enhance care coordination and provide timely access to care, leading to lower spending for nursing home residents. Future research needs to explore payment methods that encourage telehealth expansion in nursing homes.

Dataset Information

Medicare Part D claims rejections for nursing home residents, 2006 to 2010.

Publications

Medicare Part D claims rejections for nursing home residents, 2006 to 2010.

Similar Datasets

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