Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA.
National Personal Protective Technology Laboratory, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA.
Am J Ind Med. 2021 Mar;64(3):185-191. doi: 10.1002/ajim.23221. Epub 2021 Jan 11.
Workers' compensation claims among Medicare beneficiaries have not been described previously. To examine the healthcare burden of work-related injury and illness among Medicare beneficiaries, we assessed the characteristics, healthcare utilization, and financial costs among Medicare beneficiaries with claims for which workers' compensation was the primary payer.
We extracted final action fee-for-service Medicare claims from 1999 to 2016 where workers' compensation had primary responsibility for claim payment and beneficiary, claim type, diagnoses, and cost information from these claims.
During 1999-2016, workers' compensation was the primary payer for 2,010,200 claims among 330,491 Medicare beneficiaries, and 58.7% of these beneficiaries had more than one claim. Carrier claims submitted by noninstitutional providers constituted the majority (94.5%) of claims. Diagnosis codes indicated 19.4% of claims were related to diseases of the musculoskeletal system and connective tissue and 12.9% were related to disease of the circulatory system. Workers' compensation insurance paid $880.4 million for these claims while Medicare paid $269.7 million and beneficiaries paid $37.4 million.
Workers' compensation paid 74% of the total amount to providers for these work-related medical claims among Medicare beneficiaries. Claim diagnoses were similar to those of all workers' compensation claims in the United States. Describing these work-related claims helps identify the healthcare burden due to occupational injury and illness among Medicare beneficiaries resulting from employment and identifies a need for more comprehensive collection and surveillance of work-related medical claims.
先前尚未对医疗保险受益人的工人赔偿索赔进行描述。为了研究与工作相关的伤害和疾病对医疗保险受益人的医疗保健负担，我们评估了主要由工人赔偿支付的医疗保险索赔的受益人的特征、医疗保健利用情况和财务成本。
我们从 1999 年至 2016 年提取了最终行动的按服务收费的医疗保险索赔，其中工人赔偿对索赔支付和受益人的主要责任，索赔类型，诊断以及这些索赔的费用信息。
在 1999 年至 2016 年期间，工人赔偿是 330,491 名医疗保险受益人中的 2,010,200 项索赔的主要付款人，其中 58.7％的受益人的索赔超过一项。非机构提供者提交的承销商索赔构成了大部分（94.5％）索赔。诊断代码表明，19.4％的索赔与肌肉骨骼系统和结缔组织疾病有关，12.9％的索赔与循环系统疾病有关。工人赔偿保险为这些索赔支付了 880.4 百万美元，而医疗保险支付了 269.7 百万美元，受益人支付了 37.4 百万美元。
工人赔偿向这些与工作相关的医疗保险索赔的提供者支付了 74％的总金额。索赔诊断与美国所有工人赔偿索赔的诊断相似。描述这些与工作相关的索赔有助于确定由于就业而导致的医疗保险受益人因职业伤害和疾病造成的医疗保健负担，并需要更全面地收集和监测与工作相关的医疗索赔。
