Adjudication Of Claims Research Articles

Utilizing Medicare claims data for real‐time drug safety evaluations: is it feasible?,

The Centers for Medicare & Medicaid Services claims comprise an administrative database of beneficiary-specific clinical information. This study evaluates the impacts of (i) claim information updates (claims adjudication) and (ii) delay in claim processing (claims delay) on real-time evaluation of health service and drug safety signals using the Medicare database. Using Medicare claims data accumulated through May 2009 on health services rendered in 2006 and drugs dispensed in 2007, this study measures the frequency with which clinical information changes in the database as a result of (i) claims adjudication and (ii) claims delay. Over 85% of health services claims were processed within 8 weeks after the date of service, and 72% of drug claims were processed within 3 months after the dispense date. Clinical information changed for no more than 3% of unique claim groups in inpatient hospital, outpatient institutional, physician's office, and prescription drug Medicare claim settings. Claims delay is consistent across time and is minimal. Claims adjudication does not substantially impact the content of clinical information in the Medicare claims database. Therefore, the Medicare claims database provides consistent information regarding health services and prescription drugs in a manner that is prompt enough to facilitate medical product safety evaluations in real time.

Vermont Psychiatrists Back State's Single-Payer Insurance Plan

Vermont Psychiatrists Back State's Single-Payer Insurance Plan

Jurisdictional Disputes and Intermediary Liability in Cyberspace

World Wide Web or internet is global information infrastructure which exists virtually with no physical or geographical existence whatsoever and affects all sections of society due to its significance in communication, information gathering, data storage, media, entertainment, etc. It is freely accessible with nominal monitoring by anyone anywhere in the world, and thus provides wide scope for internet crimes namely defamation, pornography, cyber stalking, etc with minimal traceability. The whole activity is done through transfer of packet data which is done through different service providers known as intermediaries like, search engines, chat rooms, service providers, etc. Thus, the jurisdictional issue arises due to the world wide accessibility of the internet and the misuse of the platform for redundant activities which brings the intermediaries into picture. Thus, in the proposed article the endeavor will be to look into the extent of intermediary liability and corresponding jurisdictional issues and conflicts. Under International law the sovereign exercises its authority under their jurisdiction, but the limitation arises when it’s against a foreign state involving objectionable activities on internet. Every state has its limitations and subsequently obligations to restraint itself from jurisdictional issues of foreign state to avoid any kind of unwarranted fortification. Hence, the attempt in this article is to find out various Jurisdictional issues in the International Cyber Space. This brings the question about the jurisdiction for adjudication of claims of injury or violation of domestic standards of a nation. Further, the paper deals with the pros and cons of the victim’s position for instance the most opportune forum; correct medium to enforce the decree or execution of the order etc. To realize the working of jurisdictional aspects, one ought to understand principles on which cyberspace standards can be appreciated. Hence, the paper deals with all the principles like Territoriality Principle, Nationality Principle, Effects Principle, Protective Principle, Universality Principle etc, to analyze the application in cyberspace. The paper further deals and examines intrinsically various advance moves taken by assorted courts to draw a logical conclusion in consideration with the subject matter of jurisdiction for instance general approach, specific approach, moderate approach, expansive approach etc. In the recent scenario we have seen the rapid growth of cyber crime at a massive rate be in terms of defamation, child pornography, fraud, forgery etc. prevalent in both criminal and civil context, when such offence occurs then an imperative concern crop up on the issues like the place to try such wrongdoer & intermediary liability. All these aspects will be duly covered so as to realize the jurisdictional values of different states and thereby making a comparative analysis of two different legislators focus in prosecution for a crime by one state against another in terms of jurisdictional law in the Indian context

Workers’ Compensation for Asbestos Related Disease in Five Canadian Provinces

Workers’ Compensation for Asbestos Related Disease in Five Canadian Provinces

Children in Transit: Results of Interviews with Central American Unaccompanied Minors Encountered in Mexico

While unaccompanied minors are not one of the largest groups of migrants traveling through the Americas, they are amongst the most vulnerable of migrants. As a result of their particular vulnerabilities, they become victims of some of the most serious security problems in the region, such as human trafficking, corruption of public officials in particular police, gang violence, and other more generalized forms of violence and crime. Given that the issue of the migration of unaccompanied minor immigrants has received a lot of attention both in the United States and Mexico, and that the population of unaccompanied minors being served by the detention and removal system in the United States is very similar to those minors being detained and served in Mexico, it is important that knowledge of the children, their experiences migrating, and best practices on the treatment of unaccompanied minors should be shared amongst concerned professionals and researchers on both sides of the border. Despite the great need, there is very little research about this migration flow, particularly about Central American unaccompanied minors´ experiences in Mexico. More research is needed to aid state and non-government actors in both the United States and Mexico in developing improved procedures for apprehension, detention, adjudication of immigration claims, and repatriation. For this reason, we launched a study of unaccompanied minors experiences migrating from Central American to and through Mexico on their way to the United States. This working paper summarizes findings from a series of interviews conducted with 77 detained and non-detained unaccompanied minors encountered in Mexico. The hope is that increased knowledge of this migration flow will assist policy makers in the region improve policies for the care, detention, and repatriation of unaccompanied minors, as well as develop effective preventative practices.

Children in Transit: Results of Interviews with Central American Unaccompanied Minors Encountered in Mexico

Unaccompanied minors are amongst the most vulnerable of migrants traveling through the Americas. As a result of their particular vulnerabilities, they become victims of some of the most serious security problems in the region, such as human trafficking, corruption of public officials in particular police, gang violence, and other more generalized forms of violence and crime. Despite the great need, there is very little research about this migration flow, particularly about Central American unaccompanied minors' experiences in Mexico. More research is needed to aid state and non-government actors in both the United States and Mexico in developing improved procedures for apprehension, detention, adjudication of immigration claims, and repatriation. This working paper summarizes findings from a study of unaccompanied minors experiences migrating from Central American to and through Mexico on their way to the United States. Findings from semi-structured interviews conducted with 77 detained and non-detained unaccompanied minors encountered in Mexico are summarized, including information on the demographic and social characteristics of the interview sample; their language skills, education, and levels of literacy; their living and employment situation prior to migrating; and their migration histories and experiences. The hope is that increased knowledge of this migration flow will assist policy makers in the region improve policies for the care, detention, and repatriation of unaccompanied minors, as well as develop effective preventative practices.

Follow‐up empirical study of the performance of the New South Wales construction industry security of payment legislation

PurposeThe purpose of this paper is to report on findings of follow‐up research into the performance of the Building and Construction Industry Security of Payment Act 1999 (NSW), which was undertaken in 2007. The research aims to re‐assess the performance of the Act in the light of strong demand for adjudication of construction payment claims in New South Wales.Design/methodology/approachA cross‐sectional survey of member firms of The Master Plumbers & Mechanical Contractors Association of NSW and the National Electrical & Communications Association (NSW Chapter) was undertaken using a comprehensive multiple‐choice questionnaire administered by post. The questionnaire comprised 23 questions, whereby all but one question was of a multiple‐choice type. In answering the questions, the sampled claimants were required to draw on their understanding of the Act, and their experience with the adjudication process. Results were compared with a pilot study undertaken by the authors in 2004.FindingsThe results indicate that the object of the Act is generally being achieved. Whilst the culture of making late payments remains well entrenched in the construction industry, there appears to be a modest downward trend in the frequency of late payments since the 2004 study. It is now reasonably certain that the act of endorsing payment claims encourages communication between the parties, thus providing an opportunity for early dispute avoidance or resolution. However, the level of knowledge of the Act amongst subcontracting organisations overall has not improved since 2004 study, and may have even declined. It is clear that contractors and subcontractors are not taking full advantage of the Act.Originality/valueThe paper provides evidence of the performance of the Building and Construction Industry Security of Payment Act 1999 (NSW) between 2004 and 2007. The research compares key performance indicators for the purpose of determining whether or not the Act produces the expected result of increasing security of payment, and whether the results are consistent with the reason for the Act. It also provides important insights into the operation of similar legislation in other jurisdictions.

The Anti-Patient Psychology of Health Courts: Prescriptions from a Lawyer-Physician

Critics of the current medical malpractice tort system claim that adjudication of malpractice claims before generalist judges and lay juries contributes to rising costs of medical malpractice insurance premiums and medical care. They claim that properly deciding issues in this realm requires specialized knowledge of medicine and medical technology that juries, and even judges of general jurisdiction, do not possess. One lobbying group alleges there is a continuing medical malpractice litigation crisis in the United States, evidenced by increasing medical costs, deaths from needless medical errors, departure of physicians from the practice of medicine due to increasing medical malpractice insurance premiums, and random medical justice in medical malpractice cases. Whether there is a direct, causal correlation between the increasing cost of medical malpractice insurance premiums and medical malpractice litigation is debatable.

Saving Money, Not Lives: Why the VA's Claims Adjudication System Denies Due Process to Veterans with Post-Traumatic Stress Disorder and How the VA can Avoid Judicial Intervention

Saving Money, Not Lives: Why the VA's Claims Adjudication System Denies Due Process to Veterans with Post-Traumatic Stress Disorder and How the VA can Avoid Judicial Intervention

Equity in Veterans Affairs Disability Claims Adjudication in a National Sample of Veterans

To address potential equity concerns about the U.S. Department of Veterans Affairs' (VA) process for adjudicating military service-related disability claims. Participants were a nationally representative sample of 20,048 veterans completing the 2001 National Survey of Veterans. Sociodemographic, access, and illness correlates of both the award and rate of general disability benefits awarded by the VA were examined using an established theoretical framework. Sociodemographic, access, and illness variables were associated with both the award ("yes/no") and rate of benefits (0-100%) awarded, with combat exposure, unemployment, and physical impairment accounting for the strongest model effects. Veterans' needs were not overshadowed by factors related to demographic background or access (e.g., race, gender, insurance), reducing concerns about disparities in general VA disability disbursements. These data are timely as disability claims/payments will likely increase dramatically in the near future because of current conflicts in the Middle East.

How Diverse Are US Suburbs?

American suburbs are popularly perceived as demographically homogeneous compared with central cities. Social scientists have long challenged this perception; indeed, some cite recent evidence on suburban diversity to assert that the suburb—city distinction has become irrelevant. Here, several conceptual, methodological and theoretical improvements are introduced to improve the adjudication of claims about the extent and nature of suburban diversity. The analysis examines patterns and potential antecedents of population composition at both the suburban ring and place levels for 65 large US metropolitan areas. It is shown that rings and their constituent places are much more diverse than traditionally imagined. However, important differences still exist between suburbs and central cities on specific dimensions. It is also found that suburban diversity varies with metropolitan population size and suburban size, density, dominance and distance from the central city.

Socioeconomic Rights and Refugee Status: Deepening the Dialogue Between Human Rights and Refugee Law

Over the past two decades, international human rights law has provided an increasingly useful framework for interpreting key criteria of the definition of a refugee. A human rights-based approach to analyzing refugee status helps to increase consistency and uniformity in decision making by state parties regarding who qualifies for international protection.Michelle Foster's book, International Refugee Law and Socio-economic Rights: Refuge from Deprivation (Cambridge U. Press 2007), comes at a critical time, not only because of increasing acceptance of the connection between refugee law and human rights law and significant developments in the current understanding of economic and social rights, but also because more asylum applicants are articulating the aspects of their claims involving socioeconomic deprivation. All jurisdictions, including the United States, now recognize that socioeconomic harm can rise to the level of persecution, but inconsistencies and insecurities still obstruct attempts at coherent analysis. Foster's meticulous research, sober reasoning, and original analysis may encourage additional scholarship on these pressing issues and lead to a more sophisticated understanding of both the refugee definition and the substantive content of economic and social rights. The proper adjudication of socioeconomic claims will likely play a vital role in challenging the lingering, dominant orthodoxy of civil and political rights, help coalesce the relationship between human rights and refugee law, and promote the development of refugee law, with some coherency, as a body of law.

Product Customization and Customer Service Costs: An Empirical Analysis

We conduct a field study in a U.S. health insurance firm to examine how product customization affects the firm's cost to serve customers through its call center. In our setting, the product is a complex health insurance plan. The firm incurs substantial costs in serving the customers through its call center and in adjudicating the claims using its information systems. The firm sells either standard plans or in some instances allows customer groups to customize their plans by adding and modifying certain aspects in active collaboration with the firm. Such a collaboration process is akin to the firm cocreating products with its customers. This cocreation process should increase customers' familiarity with their coverage and improve the fit with their medical needs. Better fit and familiarity in turn, reduces customers' incentives to contact the call center for clarifications regarding the firm's product coverage. In particular, we show that customers with a customized plan call 21% less frequently than customers with a standard plan. Our results account for possible self-selection of customers to customized plans. We also show no difference in the claims adjudication cost between a standard and a customized plan exists. Overall, our results suggest customized plans may be operationally cheaper to serve than standard plans. Thus, our paper provides a link between a growing business concern (customer support cost via call centers) and a prevalent business strategy (product customization via cocreation).

Product Customization and Customer Service Costs: An Empirical Analysis

We conduct a field study with a US health insurance firm to examine how product customization affects firm’s cost to serve the customers through its call center. In our setting, the product is a complex health insurance plan. Firm incurs substantial cost in serving the customers through its call center, and adjudicating the claims using its information systems. Firm sells either standard plans, or in some instances allows customer groups to customize their plan by including, modifying certain aspects of the plan with active collaboration with firm – product co-creation. We show that the process of co-creation is such that it increases users’ familiarity with their coverage and improves the fit with their medical needs. This, in turn, reduces their incentives to call the firm’s call center for clarifications regarding their product coverage. In particular, we show that users with customized plan call 20% less frequently than users with standard plan. Our results account for any possible self selection of customers to customized plan. We also show that there is no difference in claim adjudication cost between a standard vs. customized plan. Overall, our results suggest that, customized products may be operationally cheaper to serve than standard products. Thus our paper provides a link between a growing business concern (customer support cost via call center) and a prevalent business strategy (product customization via co-creation).

Obligations in Classical Procedure

The civil law gave the praetor relatively few rules of procedure with which to manage a tribunal. Accordingly many rules of procedure were the product of the praetor's own active lawmaking. His lawmaking frequently took the form of actions and stipulations, which is to say, obligations. This essay describes a selection of law reforms where this was the case. The essay concludes with the suggestion that the praetor turned to more effective methods of enforcement, not because the older methods were poor, but because parties were more frequently turning to litigation for the adjudication of claims, and less frequently for simple arbitration.

Expert Testimony on Psychological Injury: Procedural and Evidentiary Issues

This article introduces psychologists to aspects of the legal process most pertinent to their role as expert witnesses in civil litigation. It summarizes the role of psychological evidence in the adjudication of common law tort claims, the structure of the court system, and the stages of the litigation process. It also explains the various roles a psychological expert may play during litigation and the implications of those roles for expert confidentiality and disclosure. The article then provides an overview of legal policy governing the admissibility of psychological expertise, especially as admissibility is affected by the “Daubert” standard applied in most North American courts.

Time from Medicare Part D claim adjudication to community pharmacy payment

ObjectiveTo determine the average payment time from Medicare Part D plans to community pharmacies for prescription drugs dispensed to Medicare beneficiaries. DesignNonexperimental time series. SettingUnited States in January to December 2006. Participants145 independent pharmacies and 17 regional chain pharmacy firms. InterventionReview of 2,944,526 Medicare Part D prescription drug claims adjudicated in 2006. Main outcome measuresMedian payment time and the number and proportion of claims paid, controlling for month of claim adjudication, pharmacy type, and Part D plan. ResultsThe median payment time for 2006 claims filed by all pharmacies in this study was 29.0 days (mean 39.1). The median payment time was greater for independent pharmacies (median 31.0, mean 49.1) than chain pharmacies (median 29.0, mean 36.5). Payment was slower during the first few months of the Medicare Part D benefit than later in the year. By December, approximately 40% of the claims were not paid within 30 days. Within the 12 plans identified as having the greatest number of claims in the sample, the median payment time ranged from 23.0 days to 36.0 days. ConclusionPayment times improved during 2006, but a sizable proportion of claims were not paid within 30 days. Chain pharmacies received payments sooner than independent pharmacies. Additionally, a wide variation in median payment times was observed for Part D plans. The results of this study, based on actual claims data, are not in agreement with findings from a survey of Part D plans reported by the Centers for Medicare & Medicaid Services.

Pediatricians need to understand costs, benefits of real-time claims adjudication

Under high-deductible plans and health savings accounts, more patients are expected to pay out of pocket. The amount the patient owes, however, may be difficult to determine. ![Figure][1] Dr. Francis To avoid increased collections and accounts receivables, practices need more timely

The ethics of belief and two conceptions of christian faith

This article deals with two types of Christian faith in the light of the challenges posed by the ethics of belief. It is proposed that the difficulties with Clifford’s formulation of that ethic can best be handled if the ethic is interpreted in terms of role-specific intellectual integrity. But the ethic still poses issues for the traditional interpretation of Christian faith when it is conceived as a series of discrete but related propositions, especially historical propositions. For as so conceived, the believer makes claims that fall within the province of an intellectual discipline, history, that requires evidence and rules of procedure for the adjudication of such claims. It is noteworthy how few Christian theologians and philosophers of religion deal with the issue in these terms. Alvin Plantinga is a noteworthy exception and his views are examined and criticized because, among other things, his conclusion is that any believer without having any training in biblical languages or historical studies can know that the New Testament narratives are true. The article then considers a second conception of Christian faith in which this conflict does not arise. One finds it in the works of Schleiermacher, Wittgenstein, and, surprisingly, in the conception of faith found in the early writings of Karl Barth.

Evaluating causality for occupational cancers: the example of firefighters

The evaluation of causality in cancers associated with firefighting presents problems common to other applications of occupational epidemiology in adjudication of individual claims for workers' compensation. A trend in Canada to establish legislated presumptions for compensation of firefighters created an opportunity to re-evaluate the literature applying medicolegal standards of certainty. To evaluate causality in selected cancer categories for firefighters using the criteria applied in tort litigation and workers' compensation, which is based on the weight of evidence and which is required to take into account individual factors. The epidemiological literature on cancer risk among firefighters was reviewed based on the weight of evidence rather than scientific certainty. Generalizable frameworks were formulated to define recurrent issues in assessing the evidence from epidemiological studies. The evidence for latency and for a threshold effect with duration of employment was also examined in order to provide practical guidelines. Presumption is justified for the following cancers: bladder, kidney, testicular and brain, and lung cancer among non-smokers. Non-Hodgkin lymphoma, leukaemia and myeloma (each as a class) not only present particular problems in assessment but also merit an assumption of presumption. Four analytical frameworks describe the problems in analysis encountered. The preponderance of evidence supports the presumption of causation for certain cancer, mostly rare. These frameworks are applicable to other problems of adjudication that rest on interpretation of epidemiological data. The named cancers, taking into account the special assessment issues described by each framework, are supported by sufficient evidence to conclude that a presumption is warranted but not necessarily sufficient evidence to accept as proof by a scientific standard.