title: Using insurance claims data and medical record reviews to assess the quality of medical care.
abstract: This article examines the possibilities and limitations of using computerized insurance claims and outpatient medical records to evaluate a Medicaid managed care program. The quality of medical care delivered to enrollees 1 1/2 years into the MassHealth managed care program's operation is discussed in the context of an evaluation that was conducted by the University of Massachusetts-Boston's McCormack Institute in 1993. Study results suggest that these two data sources offer adequate information to determine the quality level of primary and preventive services and lead to further suggestions for evaluating care.
authors.affiliation: College of Nursing, University of Massachusetts, Boston, USA.
authors.forename: C H
authors.initials: CH
authors.lastname: Ellenbecker
authors.forename: L
authors.initials: L
authors.lastname: Wagner
authors.forename: J
authors.initials: J
authors.lastname: Cloutterbuck
mesh_terms: D000328:Adult; D001249:Asthma / Q000628:therapy; D002648:Child; D002662:Child Health Services / Q000592:standards; D003625:Data Collection; D005260:Female; D006801:Humans; D007345:Insurance Claim Review; D008404:Massachusetts; D008484:Medicaid; D008485:Medical Audit; D008499:Medical Records; D006278:Medicare; D011314:Preventive Health Services / Q000592:standards; D012017:Referral and Consultation; D014481:United States; D014932:Women's Health Services / Q000592:standards