Independent medical review of health plan coverage denials: early trends.
Independent medical review of health plan coverage denials: early trends.
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对健康计划承保拒绝的独立医学审查：早期趋势。
DOI：
10.1377/hlthaff.23.6.163
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发表时间：
2004
期刊：
影响因子：
9.7
通讯作者：
R. Dudley
中科院分区：
文献类型：
--
作者：
Kenneth H Chuang;W. Aubry;R. Dudley
病人和医生担心健康计划会拒绝提供医疗必要服务，因此立法要求对被拒绝的服务进行独立医疗审查。在加州提交的1,400例病例中，最常见的争议领域是癌症护理、内分泌/代谢护理（特别是肥胖症）、骨科护理和神经系统疾病。手术和药房服务占病例的52%。在58%的情况下，IMR支持健康计划的决定，而在33%的情况下，健康计划的决定被推翻，这表明外部IMR在加州的医疗保健系统中提供了额外的患者保护。
Concerns among patients and physicians that health plans would deny coverage for medically necessary services has brought about legislation mandating independent medical review (IMR) of denied services. Among 1,400 cases submitted in California, the most common areas for dispute were cancer care, endocrine/metabolic care (especially for obesity), orthopedic care, and neurological disorders. Surgery and pharmacy services constituted 52 percent of cases. In 58 percent of cases, IMR upheld the health plan's decision, while in 33 percent of cases the health plan's decision was overturned, which suggests that external IMR provides additional patient protection in California's health care system.