For those providers, one out of every five medical claims has to be reworked or appealed. The good news is, many medical billing denials can be avoided. A good approach is to understand the different types of medical billing denials, pinpoint the most common billing problems and take steps to avoid them. Denials fall into two big buckets: hard and soft. Hard denials cannot be reversed or corrected, and result in lost or written-off revenue. Soft denials are temporary denials with the potential to be paid if the provider corrects the claim or sends additional information.
While working denied medical billing claims after the fact is a critical component of revenue cycle management, relying on this alone can slow cash flow to dangerous levels. A much sounder financial approach is to proactively measure the volume and causes of denied medical billing claims so they can be prevented before they occur. The following should be part of any sound denials management plan:.
Many hospitals and practices lack the technology and staff capacity to manage denials effectively, especially in light of constantly changing regulations and payer rules. Outsourcing revenue cycle management to experts like Change Healthcare who have dedicated denials management teams can be a profitable, sustainable alternative.
We can help you establish medical billing benchmarks, reduce backlogs, identify root causes of denials and augment your revenue cycle team. Table The proportions presented in the second and third panels are the most noteworthy data in table First, the second panel shows that musculoskeletal conditions account for approximately 1.
The disaggregation by developing and developed regions, however, shows that while musculoskeletal conditions account for around 3. The data also show that, of the set of musculoskeletal conditions, OA accounts for the largest burden, approximately 52 percent of the total in developing regions and 61 percent in developed regions.
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Note that the burden of disease caused by musculoskeletal conditions varies considerably by region: in Africa, mortality stratum D, musculoskeletal conditions account for less than 1 percent of the burden from all causes, while in the Western Pacific, mortality stratum B, they account for more than 3 percent of the total burden of disease.
Similarly, the relative importance of rheumatoid arthritis RA and OA varies considerably by region. In the African regions, where the prevalence of RA is low, only 12 percent of the burden created by musculoskeletal diseases is due to RA; in the Americas, however, that proportion is approximately 24 to 27 percent. RA has a prevalence of 0. In addition, OP is increasing with the aging of populations: one in three people over the age of 50 suffers a fracture because of OP.
Gout is also prevalent throughout the continent, and the HIV epidemic has spawned a variety of associated spondyloarthropathies among the aging population. Countries such as Thailand are also recognizing an increasing burden of disease caused by arthritis and trauma Jitapunkul and others Osteoarthritis is the most common condition affecting human joints and causes significant disability. The principal clinical features are pain, which varies in severity and character, and stiffness. Disability occurs as a result of pain, weakness, joint instability, and reduced range of motion.
RA has a prevalence of between 1 and 3 percent in most countries for which figures are available, but it may be slightly less common in tropical countries. The exact etiology of RA is unknown, but the evidence suggests an immune reaction, and it presents as an inflammation affecting joints and other tissues. Its clinical features can be divided into three groups: constitutional, articular, and extraarticular. Constitutional features involve tiredness, fatigue, weight loss, and fever, and articular features involve principally the synovial joints, producing pain and eventual deformity and disability.
The seronegative spondyloarthropathies are primarily inflammatory arthropathies and share several common features, including familial aggregation, asymmetric joint involvement, and mucocutaneous lesions.
These conditions may follow gastrointestinal or sexually acquired infections and can be associated with HIV. Gout and other forms of crystal arthritis tend to present as an inflammatory response to the presence of uric acid gout or various calcium crystals chondrocalcinosis. Much of the pain that produces complaints and reduced function does not emanate from a frank arthropathy, but from the soft tissues in or around a joint.
When these pains are confined to a particular area of the body's surface, they can be referred to as regional pain syndromes and may or may not be related to injury or overuse. If these pains are more widespread and are associated with specific tender points, the condition is known as fibromyalgia. Fibromyalgia is well recognized in the industrial world and has also been noted in China and Malaysia and among Tamil Indians.
The major causes of infectious arthritis can be viral, bacterial, fungal, or helminthic. Each can present as either a polyarticular presentation or a monarthritis. Many of the helminthic infections present with more generalized aches and pains and involvement of muscle tissues as well as joints. All the conditions have specific diagnostic features and treatments.
OP is characterized by low bone mass and deterioration in the microarchitecture of the bone, which leads to fracture after low or moderate trauma. The clinical features of OP are primarily due to its major outcome: fracture.
The most important fractures occur in the distal radius, vertebrae, or hip, often following minor trauma. Vertebral fractures lead to loss of height, kyphosis, and back pain. The incidence of fracture varies with country and with type of fracture. Hip fractures are low in African countries but high and increasingly reported in Australasia, Europe, and North America. Fracture risk increases with age and is beginning to have a significant impact on quality of life, mortality, and health care costs in many countries.
Rickets is caused by a mineralization defect of newly formed bone in the growing skeleton. This defect leads to an increase in the amount of nonmineralized bone tissue osteoid and a thinning of the growth plates. This condition produces bone pain, bone deformation, swelling of the joints, and growth retardation.
Rickets is primarily caused by a lack of exposure to sunshine because of climate, pollution, or overuse of clothing or sunscreens. Rickets is relatively rare in industrial countries, but it does occur as a consequence of dietary deficiency or excess clothing. Osteomalacia is the adult equivalent of rickets. It is similarly characterized by an increase in osteoid tissue and causes bone pain and fractures. It occurs primarily in the elderly in Europe and North America because of a lack of exposure to sunshine that is not compensated for by adequate vitamin D intake.
Osteomalacia may also occur in countries with abundant sunshine where clothing prevents sun exposure. Back pain accounts for the majority of musculoskeletal disease presentations to health professionals, and its lifetime prevalence exceeds 80 percent in most industrial countries. Spinal disorder refers to a wide range of specific and nonspecific musculoskeletal disorders affecting the spinal column. These conditions include congenital lesions such as scoliosis, infective problems such as osteomyelitis and neoplastic disorder myeloma or secondary cancers , and trauma and referred back pain.
The majority of individuals with acute back pain will improve significantly over a six-week period, although in many cases the pain may recur. Early diagnosis and treatment, particularly of pain, by means of a modified exercise program will reduce long-term morbidity and disability. Musculoskeletal injuries are extremely common, whether in the workplace or associated with sporting activities or with daily living.
Motor vehicle trauma, household accidents, and occupational accidents occur frequently and are a major cause of damage to the musculoskeletal system. Lack of exercise and obesity are major contributors to soft tissue disorders, OA, and back pain. Infectious forms of musculoskeletal disease depend on the environment and on the types of organisms that are prevalent.
Obesity brought about by increases in sedentary lifestyles and changes in eating patterns is becoming a major problem worldwide. Weight reduction has been demonstrated to reduce pain and disability from OA of the knee and other forms of lower limb arthropathy. In OA of the knee, weight reduction will not only reduce pain and improve mobility, but it can put off the time when surgical replacement of the weight-bearing joint is necessary.
Obesity can also be associated with back pain, and weight reduction is an important factor in reducing the recurrence of episodes of back pain and in reducing long-term disability and chronic pain. Smoking and excessive alcohol use are also associated with OP.
Adequate calcium intake 1, to 1, milligrams per day has been shown to maintain bone density and reduce the risk of axial vertebral fractures. Smoking also increases the risk of developing RA. Weight reduction and diet are also important considerations in the management of gout. Appropriate nutrition and exercise underpin many of the preventive and treatment strategies for musculoskeletal disease.
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A range of treatment approaches is available to address the multiple aspects of musculoskeletal disorders. Symptomatic treatments for musculoskeletal disease principally involve pain reduction. Nonpharmacological treatments such as massage, heat, and ice, and physiotherapeutic techniques such as ultrasound may be useful in the short term.
Pure analgesic agents such as acetaminophen should be tried initially; if no response occurs, compound analgesics or opioid derivatives, including codeine, may be useful. The side effects of the latter compounds are significant, particularly in the elderly, with constipation and disorientation being the most common. In many countries, complementary medicines traditional medicines are also used extensively, particularly for the management of pain.
These compounds remain unproven, and clinical studies to explore their worth should be encouraged. Recent years have seen the introduction of a number of specific antiosteoarthritic agents, including glucosamine, chondroitin sulfate, soybean extract, and injectable hyaluronic acid derivatives.
Clinical trials have demonstrated that glucosamine and chondroitin sulfate are beneficial in terms of pain reduction in patients with OA, but the effects are relatively small. Many cases of OA and soft-tissue rheumatism and most cases of the inflammatory forms of arthritis will require an anti-inflammatory drug as well as or instead of a pure analgesic. The nonsteroidal anti-inflammatory drugs NSAIDs have been the mainstay for treating arthritic conditions for nearly a century. These agents have similar effects on pain relief but a reduced incidence of gastrointestinal side effects, although they may produce adverse events in the renal and cardiovascular systems, such as hypertension , decreased renal function, and increased stroke and heart attacks.
The medical community now appreciates the importance of early diagnosis and treatment of RA. All patients with RA should be started on a specific antirheumatic drug on diagnosis. These drugs have been shown to be efficacious in randomized controlled trials Gabriel, Coyle, and Moreland , but each has a quite different spectrum of adverse side effects.
Even with the new biologic agents, few patients with RA actually go into complete remission, and disease activity continues despite a reduction in endpoints, such as the number of painful and swollen joints, function impairment, and pain. Most patients with RA now receive combinations of antirheumatic drugs, the most common being methotrexate, hydroxychloroquine, and sulfasalazine. Corticosteroids are also used intermittently in many cases.
Patients with RA also need to receive information about exercise programs and education on activities of daily living so that they can make informed choices in relation to their therapies. A number of therapies are available for OP, including calcitonin, calcium, bisphosphonates, hormone replacement therapy HRT , and selective estrogen receptor modifiers. Clinical trial data support the use of HRT, bisphosphonates, selective estrogen receptor modifiers, calcitonin, vitamin D and calcium supplementation, and calcitriol in reducing fracture rates in high-risk patients.
Calcium and vitamin D supplementation are recommended to reduce hip fractures among the elderly living in assisted living accommodations and nursing homes. The recommended daily requirement for calcium varies significantly between countries—for example, from 1, milligrams per day in the United States to less than milligrams per day in India. Recommended levels of vitamin D supplementation range from to 1, international units per day, particularly for at-risk aging females.
In addition to these pharmacological interventions, attention to risk factors for falling is also important. Surgical treatments vary, from the use of external splints for fractures, to interventions such as arthroscopy, internal fixation for complicated fractures, and insertion of prosthetic devices, most commonly total hip and knee replacements. Biomaterials are increasingly being used to repair bone or cartilage defects in younger patients, particularly those with sporting or other traumatic injuries.
Rehabilitation treatments include a range of activities, from single discipline interventions such as physiotherapy to multi-disciplinary programs, particularly for complex problems such as back pain. An economic discussion of health policies designed to prevent, treat, and manage musculoskeletal conditions in developing countries is inherently difficult for a variety of reasons, but primarily because of the lack of both epidemiological and cost-effectiveness data for most developing countries.
Some progress has been made by Symmons, Mathers, and Pfleger a , b ,-who-provide incidence estimates for OA and RA from epidemiological data on prevalence and relative mortality risks, although data from many areas are scant. Perhaps a more important constraint on economic evaluations in this field is the surprising number of interventions for which trial data on efficacy are inadequate. Another issue, currently the target of a concerted effort to improve practice in the field, is the lack of cross-study comparability of the results of economic evaluations of interventions for OA, RA, and OP.
One of the most important variables is the choice of comparator used to assess the cost-effectiveness of interventions. The Outcome Measures in Rheumatology Clinical Trials Economics Working Group, which was established in , has made some progress toward redressing this problem. In principle, the relevant comparator is generally the next-best alternative or alternatives to the intervention of interest.
The choice of comparator is especially important for cost-effectiveness analysis, because cost-effectiveness is a relative, not an absolute, concept; whether a particular intervention is considered efficient depends on the efficiency of other interventions and on budget constraints. This issue is a fundamental one, because a great many health sector innovations involve new ways of producing desirable effects with existing technology. The relevant consideration in such cases is the additional benefits that the innovation is expected to confer and the relative cost of achieving those benefits.
In such circumstances, the computation of incremental cost-effectiveness ratios ICERs on the basis of a no-treatment alternative is of limited use, unless that scenario is genuinely under consideration. Unfortunately, the no-treatment or, more accurately, the placebo treatment option is precisely the comparator that much of the literature has used. Another characteristic of economic evaluations in this field is that they have been performed almost entirely for developed countries. In the sections that follow, we discuss the steps we have taken in an attempt to minimize the adverse consequences of reliance on the literature for developed countries.
Nevertheless, the pragmatic approach that we have adopted is subject to some important limitations and caveats. Cost-effectiveness is a relative concept, in the sense that cost-effectiveness ratios CERs are useful only for comparing alternative ways of achieving a desired outcome—for instance, improving the quality and length of life.
Assertions that an intervention is, in its own right, cost-effective are usually based on the notion that a particular CER represents a cutoff between those interventions that are efficient and those that are not. Nevertheless, the literature routinely uses cost-effectiveness rules that are based on thresholds without the theoretically necessary explicit consideration of implicit budget constraints.
We have tried to avoid using a threshold type of approach in relation to the discussion of cost-effectiveness. Instead, we critically reviewed the cost-effectiveness literature in rheumatology to provide an indication of the relative costs and consequences of available interventions. In some cases, an intervention appears to be inefficient because it costs more and produces fewer benefits than a competing alternative or because two interventions produce identical effects but one costs less than the other.
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Nevertheless, we have provided a summary of our views—for ease of reference—as table This table summarizes our thoughts on the weight of the current effectiveness and cost-effectiveness evidence and the likelihood that developing countries might realistically consider each intervention. For the reasons given above, though, we have articulated the evidence in more detail in the text. Cross-country differences in the epidemiology of conditions of interest, the age structure of populations, and the access to health care, along with differences in relative prices, are liable to affect the cost-effectiveness of any given intervention.
Some of the substantive gaps between the developed and developing worlds may compound the problem. For example, if the price of labor relative to that of capital is consistently lower in the developing countries, capital-intensive interventions may be relatively less attractive than they are in the developed countries, especially if labor-intensive alternatives exist. To improve comparability across the literature, we adjusted reported CERs by converting them to U.
Generally, we adjusted outcomes to U. Finally, we used the U. Bureau of Labor Statistics consumer price index data for to inflate deflate the U. Thus, unless otherwise stated, all price data are expressed in U. For clarity, we have classified cost-effectiveness results by condition and also according to whether the intervention constitutes a primary, secondary, or tertiary intervention. The exception is RA, for which the management protocols are less amenable to this type of abstraction.
For RA, we found that categorizing the evidence according to a taxonomy that is problem or intervention based was more useful.
This section reviews the evidence on the cost-effectiveness of interventions designed to prevent the onset of OP. The works surveyed analyzed interventions in healthy people, primarily perimenopausal and postmenopausal women, with no established history of OP. The prophylactic effects of physical activity are generally well appreciated, and a large proportion of preventable disease is sometimes attributed to sedentary lifestyles.
Katzmarzyk, Gledhill, and Shephard estimate the relative risks for those who are inactive compared with those who are physically active for a range of conditions, including OP. Their results for Canada suggest mean OP relative risk factors of 1. The effectiveness and cost-effectiveness of programs intended to encourage lifestyle changes are generally not well established. Geelhoed, Harris, and Prince consider the effect of an intervention in Australia involving exercise and calcium supplements for healthy postmenopausal women to prevent osteoporotic fractures.
Willis analyzes the cost-effectiveness of administering calcium plus vitamin D 3 to healthy postmenopausal women in Sweden and demonstrates that this intervention is a cost-saving one for , , and year-old women with a maternal family history of hip fracture and for and year-old women with either a history of fragility fractures or a smoking habit.
In developing regions, calcium plus vitamin D therapy may be a cost-effective or cost-saving intervention if targeted at older, asymptomatic women with maternal histories of hip and other fragility fractures—especially those who smoke. A targeted strategy of this kind is likely to be the most cost-effective in regions where environmental uptake of these elements is limited for dietary or other reasons.
Geelhoed, Harris, and Prince's cost-effectiveness analysis of interventions in a hypothetical cohort of , healthy postmenopausal women includes several HRT strategies: a estrogen from age 50 for life, b estrogen from age 50 for 15 years, and c estrogen from age 65 for life.
Armstrong and others compare HRT with a no-therapy scenario in healthy postmenopausal women and examine how the risks of breast cancer and coronary heart disease CHD might influence the cost-effectiveness of the interventions over 5- and year periods, as well as a lifetime intervention of approximately 31 years. The cost-effectiveness of HRT fell as the risk of breast cancer increased.
Both the base cases in these studies assume that HRT reduces hip fracture rates, and Armstrong and others also assume reductions in CHD. These constitute important assumptions because, as Kanis and others point out, data from randomized clinical trials RCTs support the hypothesis of no effect of HRT on either appendicular fractures or CHD. Armstrong and others' study also includes a cost-effectiveness analysis of raloxifene use compared with HRT and no intervention in healthy postmenopausal women.
Their results indicate that, by comparison with raloxifene, HRT is a dominant long-term therapy for U. Kanis and others argue that existing evidence on raloxifene suggests that it has no significant effect on either appendicular fractures or CHD. On the basis of the existing cost-effectiveness evidence, the use of raloxifene as a prophylactic intervention for OP in the developing regions has little to recommend it. The following studies were concerned with interventions in people with some indication of OP, either from a bone mineral density assessment or a fracture.
The authors consider two different levels of intervention costs, those associated with HRT and those associated with HRT plus bisphosphonates, and find that the higher-cost intervention HRT plus bisphosphonates therapy was dominant for the year-old group modeled. In the context of developing countries, note both the relatively higher incidence of osteoporotic fractures among year-olds and the relatively larger size of this demographic group in Sweden.
Norlund conducted a cost-benefit analysis of fracture prevention in osteoporotic women age 50 to 54 in Sweden, assuming 70 percent participation in the screening program and an offer of HRT with 30 percent acceptance. The study provides evidence of a negative net benefit, indicating that the costs of a population screening program of this kind exceed its benefits.
Thus, population-based bone mineral density screening programs aimed at perimenopausal or post-menopausal women are likely to be a poor use of health resources in the developing world. Citing trial evidence, Kanis and others assume that calcium supplements alone reduce only vertebral fracture risks in women with established OP. They also examine the cost-effectiveness of calcium plus vitamin D on the basis of trial evidence that this combination also reduces appendicular fractures. Thus, in developing regions, calcium plus vitamin D therapy may be an attractive investment for elderly women with established OP.
These results suggest that HRT is likely to be an attractive intervention for established OP for some age groups in the developing regions. Differences in life expectancy and the underlying incidence of OP will, however, have a considerable bearing on the age at which HRT interventions may be considered desirable in each region. Raloxifene therapy is not an attractive investment for the developing regions. The cost-effectiveness evidence on nasal calcitonin is unambiguous. It is a particularly expensive intervention and represents an unattractive investment of health care resources even in wealthy developed countries.
The most favorable cost-effectiveness results for nasal calcitonin come from a study by Coyle and others , who find that both calcitonin and alendronate reduced wrist, hip, and vertebral fractures in postmenopausal women but that etidronate had no such effect on hip and wrist fractures. The results of this study were sensitive to the underlying fracture rate. Kanis and others , iv also conclude that calcitonin is "not cost-effective at any age largely because of its costs.
By contrast, both alendronate and etidronate were dominating interventions for year-olds. At current prices, calcitonin therapy is not an attractive investment for the developing regions. Kanis and others find that fluoride was generally a dominant intervention in women with established OP, because it appears to decrease the risk of vertebral fracture but to increase the risk of hip fracture, although the latter result is statistically insignificant. Fluoride is unlikely to be a desirable intervention for preventing OP in developing countries. Kanis and others report wide confidence intervals on the cost per QALY of an alfacalcidol intervention.
This result is largely due to substantial variation in the apparent vertebral, hip, and humeral fracture risk available from RCTs. This report was not written with the Pinto in mind; rather, it concerns fuel leakage in rollover accidents not rear-end collisions , and its computations applied to all Ford vehicles, not just the Pinto. Nevertheless, it illustrates the type of reasoning that was probably used in the Pinto case. The authors go on to discuss various estimates of the number of people killed by fires from car rollovers before settling on the relatively low figure of deaths per year.
Can a dollars-and-cents figure be assigned to a human being? NHTSA thought so. It broke down the costs as follows:. Future productivity losses Direct. Putting the NHTSA figures together with other statistical studies, the Ford report arrives at the following overall assessment of costs and benefits: Benefits. Ford puts the figure at 23; its critics say the figure is closer to According to the sworn testimony of Ford engineers, 95 percent of the fatalities would have survived if Ford had located the fuel tank over the axle as it had done on its Capri automobiles.
The Pinto then acquired a rupture-proof fuel tank. In Ford was obliged to recall all Pintos for fuel-tank modifications. The gas tank of the Pinto exploded on impact. In the fire that resulted, the three teenagers were burned to death. Ford was charged with criminal homicide. The judge in the case advised jurors that Ford should be convicted if it had clearly disregarded the harm that might result from its actions, and that disregard represented a substantial deviation from acceptable standards of conduct.
On March 13,, the jury found Ford not guilty of criminal homicide. For its part, Ford has always denied that the Pinto is unsafe compared with other cars of its type and era. Some observers thought not when Twenty years later an Atlanta jury held the General Motors Corporation responsible for the death of a Georgia teenager in the fiery crash of one of its pickup trucks.
Expense seems to be the issue, too, when it comes to SUV rollovers After nearly three hundred rollover deaths in Ford Expolers equipped with Firestone tires In the late s, Congress mandated NHTSA to conduct rollover road tests on all SUVs Previously, the agency had relied on mathematical ferulas based on accident statistics to evaluate rollover resistance rather than doing real-world tests.
The Chevrolet Tahoe and the Ford Explorer, in particular, have between a 26 and a 29 percent chance of rolling over in a single-vehicle crash, almost twice that of models from Honda, Nissan, and Chrysler. The same is true of side-curtain airbags to protect occupants when a vehicle rolls over. Improved design—wider wheel tracks, lower center of gravity, and reinforced roofs to protect passengers in a rollover—would also help.