Claims Files Research Articles

A sampling strategy for longitudinal and cross-sectional analyses using a large national claims database.

The United States (US) Medicare claims files are valuable sources of national healthcare utilization data with over 45 million beneficiaries each year. Due to their massive sizes and costs involved in obtaining the data, a method of randomly drawing a representative sample for retrospective cohort studies with multi-year follow-up is not well-documented. To present a method to construct longitudinal patient samples from Medicare claims files that are representative of Medicare populations each year. Retrospective cohort and cross-sectional designs. US Medicare beneficiaries with diabetes over a 10-year period. Medicare Master Beneficiary Summary Files were used to identify eligible patients for each year in over a 10-year period. We targeted a sample of ~900,000 patients per year. The first year's sample is stratified by county and race/ethnicity (white vs. minority), and targeted at least 250 patients in each stratum with the remaining sample allocated proportional to county population size with oversampling of minorities. Patients who were alive, did not move between counties, and stayed enrolled in Medicare fee-for-service (FFS) were retained in the sample for subsequent years. Non-retained patients (those who died or were dropped from Medicare) were replaced with a sample of patients in their first year of Medicare FFS eligibility or patients who moved into a sampled county during the previous year. The resulting sample contains an average of 899,266 ± 408 patients each year over the 10-year study period and closely matches population demographics and chronic conditions. For all years in the sample, the weighted average sample age and the population average age differ by <0.01 years; the proportion white is within 0.01%; and the proportion female is within 0.08%. Rates of 21 comorbidities estimated from the samples for all 10 years were within 0.12% of the population rates. Longitudinal cohorts based on samples also closely resembled the cohorts based on populations remaining after 5- and 10-year follow-up. This sampling strategy can be easily adapted to other projects that require random samples of Medicare beneficiaries or other national claims files for longitudinal follow-up with possible oversampling of sub-populations.

History of appeal of notarial deeds or refusal to perform them in court in Ukraine (late 18th - early 20th centuries)

The article is devoted to judicial control over notarial activities during the times of Austrian and Russian rule on Ukrainian lands (end of the 18th - beginning of the 20th century).&#x0D; It is noted that the 19th century is a significant period for the domestic notary, since it is at this time that it is formed as an independent institution in the system of law enforcement agencies. Two types of notaries were built on Ukrainian lands as part of the Austrian and Russian empires: Latin and state. As a result, the author conducts a comparative legal study of the mechanism of challenging notarial actions or refusal to perform them in court in different types of notary offices that were built in Ukraine at that time.&#x0D; It is claimed that the Russian notarial legislation was based on the Austrian one, in particular the Austrian Notarial Order of 1855 was laid as the basis of the Russian Regulation on the Notarial Part of 1866.&#x0D; It is concluded that it was not possible to build a Latin-type notary in Russia due to the lack of civil society and the prerequisites for its formation, as well as the desire of the state to put notary bodies under its control.&#x0D; On the other hand, the mechanism of judicial control over the activities of notaries in the two empires was similar. A notary public could be subject to civil, criminal and disciplinary liability for failure to fulfill his duties. It was within the framework of the latter that the institution of judicial appeal of notarial acts or refusal to perform them developed. Disciplinary proceedings carried out by the courts (in Austria also by the notary chamber as a notary self-governing body) regarding the consideration of such complaints were carried out outside the civil process, but it was possible to file claims to challenge the legal force of notarial acts under the rules of civil procedure. This was allowed by both the Russian Statute of Civil Procedure of 1864 and the Austrian Civil Procedure Code of 1895.

Entrepreneurial Risk in Conditions of Economic Crisis: Analysis of Law Enforcement Practice

The significance of the risk category is generally recognized in Russian civil law. This institution becomes even more relevant in times of crisis, in times of economic instability and market volatility. An analysis of current judicial practice demonstrates that during the COVID-19 coronavirus pandemic and the introduction of sanctions restrictions, entrepreneurs were often forced to resort to amendment and termination of contracts due to a significant change in circumstances and to file claims for exemption from liability for violation of contractual obligations due to the occurrence of the force majeure. Russian courts apply these legal institutions in close connection with the category of business risk, however, due to the lack of a legal definition of this term and the wide variety of concepts of risk in legal doctrine, judicial discretion plays a significant role in resolving cases. Extremely broad discretionary powers of judges and legal uncertainty regarding business risk can lead to destabilization of civil law transactions and negatively affect the economic development of Russia. In this regard, the author advocates consolidating the concept of business risk, as well as its permissible and justified limits, if not at the legislative level, then at least in the explanations of Russian higher courts.

Legal Position of Syndicated Creditors in Submitting Claims on Debtors in the Application Process for Postponement of Debt Payment Obligations (PKPU) and the Legal Impact

The arrangement of parties who can file claims in the process of suspension debt payment obligations has been regulated in Article 270 of Law number 37 of 2004 concerning Bankruptcy and Suspension of Debt Payment Obligations. The arrangement of parties who can file bills in the suspension of debt payment process still causes several problems in its implementation. This occurs in the suspension of debt payment process against debtors in syndicated loans which still creates uncertainty in its implementation because the suspension of debt payment Law does not specifically regulate it but only provides an explanation, so it is important to raise the issue regarding the party authorized to file claims against debtors in credit. Syndication. Meanwhile, the method used in this research is normative juridical research by examining library materials, namely the Civil Code and the suspension of debt payment Law. The suspension of debt payment Law has definitively determined the parties who can file claims, but to file claims in syndicated loans still creates dualism that arises due to the distinctive characteristics of syndicated loans, namely that there are agents who act as attorneys for syndicated participants to represent their interests. In principle, there is only one creditor in a syndicated credit agreement, namely a credit syndicate represented by an agent. Because the agent represents the interests of the syndicated participants, the agent has strong authority to take legal actions including submitting and registering claims to the Management in suspention of debt payment with the approval of the majority creditors.

FAKTOR PENYEBAB KETIDAKTEPATAN KODE DIAGNOSA SEBAGAI SYARAT PENGAJUAN KLAIM PASIEN RAWAT INAP PESERTA BADAN PENYELENGGARA JAMINAN SOSIAL KESEHATAN DI RUMAH SAKIT UMUM SURYA HUSADHA DENPASAR

Background: Writing a complete diagnosis can produce the right coding because the diagnosis is written in a complete, clear, specific, and consistent manner. Writing clear, complete, and consistent diagnoses can produce quality data (Hatta, 2008). Based on observations made for 1 month from 23 January to 23 February 2023, 39 claim files were returned by the Health Social Security Administering Body due to inaccuracies in the diagnosis code.. This was caused by the doctor's notes that were not clearly legible in 24 (61.5%) claim files and the use of abbreviations in patient diagnoses in 15 (38.5%) claim files, while the purpose of this study was to find out the relationship between doctor's notes that were not clearly legible and the use of abbreviations for patient diagnoses for inaccuracies in the diagnosis code as a condition for filing claims for inpatient patients participating in the Health Social Security Administration at Surya Husadha General Hospital. Methods: The design in this study used a quantitative analytic descriptive research design and porpusive sampling research type, and the sample in this study were all inpatient claim files returned by Health Social Security Administering Body claims for inaccuracies in the diagnosis code totaling 39 claim files. Doctor's notes were illegible in 24 (61.5%) claim files and the use of abbreviations in patient diagnoses in 15 (38.5%) claim files. Result: From the results of this study it was found that there was a relationship between illegible doctor's notes and inaccuracy of the diagnostic code with a p value of 0.001 &lt;0.05 and the use of abbreviations in patient diagnoses for inaccuracy of patient diagnosis codes with a p value of 0.003 &lt;0.05.

Vicarious Liability in Personal Data Protection

This study explores the legal responsibility and ideal concepts in compensating victims of personal data misuse, focusing on the ambiguous regulations within Indonesia's Personal Data Protection Act (UU PDP). The research, conducted through a normative-juridical approach employing conceptual and legislative methods, assessed primary legal materials including UUD NRI 1945 and UU PDP, along with secondary legal materials like books, journals, and non-legal materials such as language dictionaries. The results identified an existing lack of clarity in the UU PDP regarding the embraced accountability concept, potentially impairing the optimal filing of compensation claims by personal data subjects. It concluded that adopting the legal accountability concept of vicarious liability could ensure legal certainty for victims and simplify obtaining compensation for personal data misuse. The study implies the necessity for the adoption of vicarious liability, particularly in compensating victims of data misuse, by future institutions involved in personal data protection.&#x0D; Highlights:&#x0D; &#x0D; Ambiguity in Regulation: The UU PDP's lack of clarity concerning legal accountability may lead to suboptimal compensation claims for personal data subjects.&#x0D; Ideal Concept Identified: The vicarious liability concept was determined as an ideal basis for legal accountability in compensating victims of personal data misuse.&#x0D; Implication for Future Institutions: The findings suggest the importance of adopting vicarious liability in future data protection institutions, particularly regarding compensation for data misuse victims.&#x0D; &#x0D; Keywords: Vicarious Liability, Personal Data Protection, Legal Responsibility, Compensation, Normative-Juridical Analysis

International Patent Law Conflicts With the Right of Access to Medicines and Healthcare: Key Aspects

This article is dedicated to the legal conflicts between international patent law and the right ofaccess to medicines and healthcare. This article discusses the problem above under the light ofthe framework of the international agreements, mainly WTO Agreement on Trade-RelatedAspects of Intellectual Property Rights (TRIPS Agreement) and Doha Declaration on the TRIPSagreement and public health. As we know, patents give exclusive rights to the inventors to usetheir innovations for a long period of time. This limits the ability of public to get easy access tomedications, consequently to indispensable healthcare. It is undoubtable that the quality of lifeand the healthcare of the public is an absolute priority. On the contrary, the expropriation ofpatent rights, inadequate compensation of damages for issuing the compulsory licensing mayhave irreversible consequences for the states. Foreign investor may file claims against thegovernmental authorities to ad hoc or permanent arbitral institutions.

Factors Causing Pending Claims at Nyi Ageng Serang Regional General Hospital

Nyi Ageng Serang Regional General Hospital submits monthly collective claims for the Social Health Insurance Administration Body patients. Based on the observations made at the Nyi Ageng Serang Regional General Hospital, the Social Health Insurance Administration Body claim file was pending by the Social Health Insurance Administration Body verifier because it needed to be confirmed. The pending claims will cause the payment of claims from the Social Health Insurance Administration Body to the hospital to be delayed, and it might affect service activities and financing for the hospital. Pending claims must be explored more deeply to the causal factors so they can be handled appropriately. This study aims to describe the factors causing pending claims for the Social Health Insurance Administration Body at the Nyi Ageng Serang Regional General Hospital. Data collection techniques used observation techniques, documentation studies, and interviews. Data analysis was performed using descriptive analysis. External factors that have caused pending claims include discrepancies in claim rates with the Minister of Health Regulations, incorrect codes, and incomplete codes. Meanwhile, the internal factors causing pending claims, according to the 5M management element, were the Man, Material, and Method factors.

The impact of the baby friendly hospital initiative on healthcare utilization among newborns insured by Medicaid in Delaware

BackgroundThe Baby Friendly Hospital Initiative was created to enhance breastfeeding, although its impact on infant healthcare utilization is unclear. Breast feeding infants are vulnerable to readmission soon after birth secondary to dehydration and hyperbilirubinemia. Breastfeeding can also protect infants from unnecessary health care utilization later in life by preventing infection. The objective of this study was to examine the impact of the Baby Friendly Hospital Initiative on readmissions and emergency department utilization among Medicaid births in Delaware.MethodsThe study was a quasi-experimental design. Medicaid claims files were used to study births at five hospitals in Delaware born between January 1, 2014, and December 31, 2018, and covered under Medicaid at time of birth. Three hospitals were designated Baby Friendly, two were not and served as controls. Outcomes included Emergency Department (ED) utilization and readmissions within 30 days and one-year of birth hospitalization. Exposure to the Baby Friendly Hospital Initiative was determined by year and hospital of birth. Logistic regression and interrupted time series segmented regression analysis with controls were used to assess the effect of Baby Friendly Hospital Initiative on healthcare utilization.ResultsIn total, 19,695 infants were born at five hospitals with 80% (15,939) born at hospitals that were designated Baby Friendly. ED utilization and readmissions over the 1st year of life for breastfeeding related diagnosis at the Baby Friendly hospitals occurred in 240 (1.5%) and 226 (1.4%) of infants, respectively. Exposure to the Baby Friendly Hospital Initiative was associated with increased odds of all cause 30-day readmission (AOR: 1.15; 95% CI: 1.03–1.28) but not readmissions over the 1st year of life. While 30-day ED visits did not change after BFHI, one-year ED visits were reduced (0.91, 95% CI 0.86–0.97). A significant negative trend was seen over time for ED utilization post BFHI compared to controls (B: -5.90, p < 0.01).ConclusionThere was a small observed increase in the odds of all cause 30-day readmissions with no change in one-year readmissions after BFHI in Delaware. Although there were no observed changes in 30-day ED utilization, there was a reduction in one-year ED utilization following the implementation of the Baby Friendly Hospital Initiative in Delaware birth hospitals. Our data help to inform policy and decision making for statewide systems of care that may be used to support breast feeding.

Effectiveness of Transitional Care Program among High-Risk Discharged Patients: A Quasi-Experimental Study on Saving Costs, Post-Discharge Readmissions and Emergency Department Visits

Transitional care programs (TCPs), where hospital care team members repeatedly follow up with discharged patients, aim to reduce post-discharge hospital or emergency department (ED) utilization and healthcare costs. We examined the effectiveness of TCPs at reducing healthcare costs, hospital readmissions, and ED visits. Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement (BPCI) program adjudicated claims files and electronic health records from Greenville Memorial Hospital, Greenville, SC, were accessed. Data on post-discharge 30- and 90-day ED visits and readmissions, total costs, and episodes with costs over BPCI target prices were extracted from November 2017 to July 2020 and compared between the “TCP-Graduates” (N = 85) and “Did Not Graduate” (DNG) (N = 1310) groups. As compared to the DNG group, the TCP-Graduates group had significantly fewer 30-day (7.1% vs. 14.9%, p = 0.046) and 90-day (15.5% vs. 26.3%, p = 0.025) readmissions, episodes with total costs over target prices (25.9% vs. 36.6%, p = 0.031), and lower total cost/episode (USD 22,439 vs. USD 28,633, p = 0.018), but differences in 30-day (9.4% vs. 11.2%, p = 0.607) and 90-day (20.0% vs. 21.9%, p = 0.680) ED visits were not significant. TCP was associated with reduced post-discharge hospital readmissions, total care costs, and episodes exceeding target prices. Further studies with rigorous designs and individual-level data should test these findings.

Regional and racial disparities in major amputation rates among medicare beneficiaries with diabetes: a retrospective study in the southeastern USA

ObjectiveWhile rates for non-traumatic lower extremity amputations (LEA) have been declining, concerns exist over disparities. Our objectives are to track major LEA (MLEA) rates over time among Medicare beneficiaries residing...

Better Nurse Practitioner Primary Care Practice Environments Reduce Hospitalization Disparities Among Dually-Enrolled Patients.

Over 12 million Americans are dually enrolled in Medicare and Medicaid. These individuals experience over twice as many hospitalizations for chronic diseases such as coronary artery disease and diabetes compared with Medicare-only patients. Nurse practitioners (NPs) are well-positioned to address the care needs of dually-enrolled patients, yet NPs often work in unsupportive clinical practice environments. The purpose of this study was to examine the association between the NP primary care practice environment and hospitalization disparities between dually-enrolled and Medicare-only patients with chronic diseases. Using secondary cross-sectional data from the Nurse Practitioner Primary Care Organizational Climate Questionnaire and Medicare claims files, we examined 135,648 patients with coronary artery disease and/or diabetes (20.0% dually-eligible, 80.0% Medicare-only), cared for in 450 practices employing NPs across 4 states (PA, NJ, CA, FL) in 2015. We compared dually-enrolled patients' odds of being hospitalized when cared for in practice environments characterized as poor, mixed, and good based on practice-level Nurse Practitioner Primary Care Organizational Climate Questionnaire scores. After adjusting for patient and practice characteristics, dually-enrolled patients in poor practice environments had the highest odds of being hospitalized compared with their Medicare-only counterparts [odds ratio (OR): 1.48, CI: 1.37, 1.60]. In mixed environments, dually-enrolled patients had 27% higher odds of a hospitalization (OR: 1.27, CI: 1.12, 1.45). However, in the best practice environments, hospitalization differences were nonsignificant (OR: 1.02, CI: 0.85, 1.23). As policymakers look to improve outcomes for dually-enrolled patients, addressing a modifiable aspect of care delivery in NPs' clinical practice environment is a key opportunity to reduce hospitalization disparities.

Do No Harm: Whistleblowing on Medicare Fraud

ABSTRACT The high incidence of healthcare fraud in the United States resulted in the creation of multiple outlets to report fraud, such as the Medicare Hotline, the Office of the Inspector General, and the filing of False Claim Act lawsuits associated with whistleblower rewards. Despite the high incidence, examinations of whistleblowing factors in this industry, such as whistleblowers’ professional roles and fraud types, are scarce, and the interaction effects of these factors are unknown. In this study, participants from two different professional roles disclose their likelihood of reporting Medicare fraud through the aforementioned three reporting outlets conditional on two different billing fraud types. The results indicate that although workers in both professional roles show similar likelihoods to report fraud regardless of the reporting outlet, fraud type and its interaction with the professional role influence some but not all the reporting likelihoods.

Abstract 17225: Association Between Moderate and Vigorous Physical Activity on Long-Term Heart Failure Risk: The Cooper Center Longitudinal Study

Introduction: Regular physical activity (PA) is associated with a lower risk of heart failure (HF). However, the relative contributions of moderate and vigorous intensity exercise on HF risk is still unclear. We characterized the association between moderate (MPA) and vigorous physical activity (VPA) on the long-term risk for HF. Methods: We included participants free from baseline coronary disease in the Cooper Center Longitudinal Study (CCLS) who were Medicare eligible at age 65 years. PA was measured from a self-report instrument that included duration (minutes/week) and intensity of exercise (METs), with moderate intensity as 3-6 METs and vigorous intensity as 6 METs. Incident HF was defined as a HF hospitalization event (primary diagnosis) from Medicare claims files. MPA and VPA were considered separately as continuous variables. The association between baseline PA and incident HF was evaluated by Cox proportional hazards models adjusted for standard HF risk factors. Results: Of 32,322 individuals (mean age 50.9, 74.2% men), the mean number of hours/week of MPA and VPA was 1.2 and 1.4, respectively. 56.42% reported zero MPA and 42.6% reported zero VPA. Higher levels of VPA, but not MPA, were associated with a lower burden of HF risk factors. After 275,373 person-years of follow-up, we observed 954 incident HF hospitalizations. MPA was not significantly associated with HF risk in either model. VPA was inversely associated with HF risk in age-adjusted models. After multivariable adjustment, VPA was not associated with HF risk (see table). Conclusions: Midlife VPA, but not MPA, was associated with a lower risk for HF. However, after additional adjustment for traditional HF risk factors, the association between higher VPA and HF risk was no longer significant. These findings suggest that the inverse association between midlife VPA and long-term HF risk may be mediated by a more favorable risk factor profile.

Utilization of high-cost prostate cancer therapies by oncologists in the merit-based incentive payment system (MIPS).

73 Background: TheMerit-Based Incentive Payment System (MIPS) is currently the only federally mandated value-based payment model for oncologists. MIPS uses cost and quality metrics to assign oncologists an overall MIPS score, where higher scores correspond to greater payments for practices. The extent to which MIPS delineates between oncologists administering high-cost anti-cancer therapeutics with unproven benefit is unknown. In this study, we investigated administration of low-value prostate cancer therapies by differently scored oncologists. Methods: We identified MIPS scores for oncologists using publicly available data for the year 2019. We cross referenced these scores with the 20% restricted sample of Medicare fee-for-service claims for 2019 using provider National Provider Identifications (NPIs). We then identified patients who were treated by these oncologists for prostate cancer using ICD-10 diagnosis codes for prostate cancer. Use of Sipuleucel-T (Provenge) and Radium Ra 223 dichloride (Xofigo), two low-value treatments with unproven benefit in prostate cancer, was identified using HCPCS codes in the claims file. The top 25 and bottom 25 percentile of oncologists based on their MIPS scores were identified using summary statistics. Odds ratios (OR) and corresponding confidence intervals (CI) were generated for Sipuleucel-T and Radium Ra 223 dichloride use by top 25 and bottom 25 percentile MIPS scores. Results: We identified 533,966 claims for prostate cancer treated by oncologists with a MIPS score in 2019. Of these claims, there were 100 instances of Sipuleucel-T use and 308 instances of Radium Ra 223 dichloride use (500 instances of Sipuleucel-T and 1540 instances of Radium Ra 223 dichloride if scaled to national use). Oncologists in the lowest 25% of MIPS scores less likely administered Sipuleucel-T (OR 0.25, 95% CI 0.12, 0.54) while those in the highest 25% did not show a significant trend (OR 1.36, 95% CI 0.90, 2.07). Oncologists in the lowest 25% of MIPS scores more likely administered Radium Ra 223 dichloride (OR 1.53, 95% CI 1.21, 1.95) while those in the highest 25% less likely administered the drug (OR 0.66, 95% CI 0.49, 0.88). Conclusions: Low MIPS scoring oncologists were less likely to utilize Sipuleucel-T and more likely to use Radium Ra 223 dichloride to treat prostate cancer. Our findings suggest that the MIPS program may be ineffective at measuring and incentivizing high value care among oncologists. Specialty-specific recalibration of cost and quality measures is needed to ensure that policy efforts to promote value-based care do not compromise healthcare quality and outcomes. [Table: see text]

Impact of remote symptom monitoring (RSM) with electronic patient-reported outcomes (ePRO) on hospitalization, survival, and cost in community oncology practice: The Texas Two-Step study.

569 Background: There is rising interest to integrate electronic patient reported outcomes (ePRO) solutions for symptom monitoring to enhance the quality of care in oncology and to support value-based care (VBC) models. Step 1 of the Texas Two-Step Study demonstrated successful implementation of an ePRO system in &gt;200 sites of service of a large community oncology practice. We now report step 2 of our study which evaluates the impact of ePROs in reducing adverse outcomes and cost of care among cancer patients enrolled in CMS’ Oncology Care Model (OCM) VBC program. Methods: This observational study focused on patients with metastatic cancer enrolled in the OCM program at Texas Oncology between July 2020 to December 2020. Patients who enrolled and completed ≥1 survey via the ePRO tool defined the study arm. Patients were matched and balanced for confounders with propensity score matching (PSM). Data used for this analysis included data collected from OCM claims files and the ePRO vendor database. Adverse events (death (D)/hospitalizations (H)/Emergency Department (ED) visits), average H/ED visits per patient, average length of H, total Medicare cost (i.e. Medicare paid amounts for different services except Part D drugs) were study measures. Mann-Whitney U and Chi-Square tests compared continuous and categorical variables, respectively, and multivariable logistic regression was used to adjust the covariates (age, gender, cancer type, therapy line). Results: Out of 831 metastatic cancer patients, 458 matched patients (229 patients per group) were identified through PSM. In our matched cohort, ~52% of patients were male, with a mean age of 74 years. Mean total adverse events were significantly less (0.98 vs 1.41 p-value: 0.007) in the study group (SG) as compared to control (C). We observed decreased rates of H (20% vs 32.5%; p value: &lt;0.05), ED (38.4% vs 42.3%) and D (11.8% vs 16.6%) in the SC compared to C. After adjusting for covariates, the SG had decreased odds of H (aOR: 0.51; 95% CI 0.33, 0.8; p-value 0.002) compared to C. Similar, but not statistically significant, effects were observed in the case of D and ED visits. Average number of H (0.28 vs 0.52, p-value-0.003) and ED visits (0.51 vs 0.75, p value: 0.01) per patient were also lower in the SG as compared to C. In addition, mean H duration per patient (days) was significantly less in the SG as compared to C (1.9 vs 3.2, p value: 0.03). ePRO engagement also reduced the total cost of care (per member per month) by an average of $1146. Conclusions: RSM with ePROs reduced adverse outcomes and cost of care among patients with metastatic cancer in a large multi-site community oncology practice. Additional studies to include a larger patient population are warranted to strengthen these observations. This work suggests that ePRO use in the community setting does improve patient outcomes and enhance VBC.

Tinjauan Penyebab Pengembalian Berkas Klaim Biaya Pelayanan Pasien Rawat Inap BPJS Kesehatan di Rumah Sakit Pelabuhan Jakarta Tahun 2022

In the process of submitting a BPJS Health Claim, some requirements must be completed by the Health Facility. Of these requirements, the BPJS Health party will know that the claim submission can be paid or returned/delayed. This research was conducted to find out the reasons for returning the claim file for BPJS Kesehatan inpatient care at the Jakarta Harbor Hospital in 2022. The method in this study used descriptive research with a quantitative approach. The results of the study were 118 samples (6.7%) of 1,762 files, the highest returned cause was an inaccuracy in the coding of diagnoses/actions of 49 (42%), and the second highest was not fulfilling inpatient administration 18 (15%), other causes - others as much as 51 (43%). 3 factors from 5M are the cause of returning claim files, namely the human factor: casemix officers who are not diligent, lack of coder understanding/knowledge, and lack of accuracy in the filing department so that files are missed/left behind, machine: there is an upgrade to the latest version of the INA-application CBGs and V-Claim are also the Ministry of Health's newest program which requires TB patients to be inputted into the SITB application, Material: incomplete claim requirements files. While the money and method factors are not an obstacle or a cause for returning claim files. It is recommended to evaluate and re-socialize the reasons for returning BPJS Health claims so that the process of submitting BPJS Health claims is carried out properly and is 100% accepted.

Designing NLP applications to support ICD coding: an impact analysis and guidelines to enhance baseline performance when processing patient discharge notes

Financial costs are a major concern in the healthcare system, with medical billing and coding playing a key role in facilitating transactions and financing procedures. Billing involves filing claims with insurance companies and requires scrutiny of clinical summaries and electronic health records to correctly match diagnoses, prescriptions, and procedures to standardized codes. Accuracy in assigning International Classification of Diseases (ICD) codes is critical to proper reimbursement of care. Incorrect codes waste time and resources, and cause administrative and financial problems for hospitals, insurance companies and patients. Manual medical coding is a labor-intensive and error-prone process that creates additional administrative burden and inconvenience for hospitals, insurance companies, and patients. To simplify the process, clinical records are often processed to automatically identify and extract clinical concepts and corresponding ICD codes. Deep learning and natural language processing techniques have shown promise in a variety of tasks but applying them to medical coding has been challenging. Accurate coding requires a deep understanding of medical terminology, context, and guidelines that may be difficult to capture with traditional deep learning methods. Although deep learning shows promise in healthcare, its specific impact on ICD coding is not fully understood, and translating scalable deep learning methods into practical improvements in ICD coding remains a challenge. Evaluating deep learning models under the scenarios of real-world coding and comparing them to established practice is critical to determining their true effectiveness. In this work, we address the automation of ICD coding by highlighting pitfalls and contrasting different perspectives. We investigated automatic ICD coding using baseline machine learning models, with a focus on identifying ICD-9 codes in discharge notes from Medical Information Mart for Intensive Care (MIMIC) database. A thorough evaluation of different models and approaches is crucial to avoid over-reliance on any method. Our findings show that simpler methods can achieve comparable results to deep learning models while still requiring fewer computational resources.

Analysis of Determinants of Motivation and Regulatory Understanding on the Speed of Covid-19 Claim Services in Sidoarjo Regency Hospital

Background: There is a file of disputed Covid-19 claims which is an indication of less than optimal employee performance. The claim rate of Covid-19 services is inseparable from the influence of the service revenue rate, the service revenue provided as well as motivation and regulation understanding of COVID-19 service. Purpose: This study aims to analyze the effect of services revenue rate, service revenue, work motivation, and regulations understanding on the claim rate, the effect of the service revenue rate and services revenue received on work motivation, the influence of the service revenue rate of services and services revenue received on regulation understanding. Methods: This research is a correlation research with the cross sectional method. The sample used was RSUD employees who were involved in the process of filling in the Covid-19 claim file from the start until the claim was received, 150 people, with the proportional random sampling technique. Data collecting techniques used in this study is a questionnaire, which was then analyzed by Partial Least Square analysis. Results: The service revenue rate has no significant effect on the claim of Covid-19 service rate, while service revenue, motivation, and regulations understanding have a significant effect on the Covid-19 claims rate. Meanwhile, services revenue rate and the service revenue significantly influences Human Resource motivation, the services revenue rate does not significantly affect regulations understanding, while services revenue has a significant effect on regulations understanding. Conclusion: Services rate is not able to encourage the claims rate. The service revenue, HR motivation, and regulations understanding are variables that can support the claims rate. The services revenue rate and the service revenue can trigger HR motivation. The rate at which services are revenued is not a variable capable of supporting understanding regulatory. The service rate encourage the regulation understanding.

Why presumptions are important in occupational health: The example of COVID-19 infection as an occupational disease.

Workers who become ill or injured on the job while undertaking extraordinary risks on behalf of the public are, at times, granted facilitated access to workers' compensation (WC) benefits through the application of presumptions in the compensation process. Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, a broad range of occupational groups faced an elevated risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure at work to perform vital services to maintain our food supply, sustain needed transportation, provide health care, assure energy supply and others. Some states or jurisdictions in the United States recognized both the risk and the service of these workers by enacting COVID-19 presumption laws to streamline selected essential workers' eligibility for WC benefits. Other states did not. Results of these contrasting public approaches permit an examination of the impact of presumptions in compensation by examining the frequency and outcomes of COVID-19 claims in "COVID-19 presumption" and "nonpresumption" states. Despite state-level variations in economic response to the pandemic, industry mix, and presumption eligibility criteria, the use of COVID-19 presumptions appears to have substantially increased claim filing rates and improved access to benefits. Lastly, the additional costs of COVID-19 claims to employers and insurers were lower than initially predicted. In response to future airborne infectious disease outbreaks, workers' compensation presumption laws should be universally implemented to permit a broad range of high-risk workers to work on the public's behalf without fear of losing wages and incurring medical expenses associated with a work-related viral exposure.