The factors related to the withholding of the claims of additional payments from care management organizations to insurance payers in Tokyo

Abstract

  In order to clarify the incidents of withholding and the factors associated with the withholding of claims of additional payments from care management organizations to insurance payers of Tokyo under the public long-term care insurance program, we conducted a mail survey. 1,293 care management organizations consented to participate in the present survey research. The response rate was 50.4%. The ratios of the withholding of payment claims for care management services for the elderly with dementia, the elderly leading solitary lives, and intake assessment were lower than 20%. On the other hand, the rations of the withholding of payment claims for discharge planning, coordination services for medical care, and specialized services were over 30%. One of the significant factors related to the high rations was the size of the care management organizations. The small-size organizations had high ratios, and the results imply that small-size organizations may have downward spirals in financial management. However, care management organizations collaborating with medical settings and employing medical personnel had low rations, and the results imply that care managers in the organizations can easily have contact with physicians. Moreover, the results of analyses concerning the reasons for withholding payment claims showed that the significant factors related to the high ratios were “subjective” factors such as “troublesome” and “poor skills” in claiming, while the significant factors related to the low ratios were “objective” factors such as difficulties in obtaining required documentation and a few cases of necessity for collaboration with medical settings. In conclusion, administrators in care management organizations should overcome “subjective” factors and properly operate the claims of additional payments in order to improve financial management..