Healthcare spending is on the rise. The federal government has begun several initiatives to control costs, increase efficiency, and increase quality. Revisiting one of the ACA, Medical Loss Ratio.
In the 1970s, as part of the extended managed care infrastructure, new external institutions for supervision of medical necessity, appropriateness, and quality of care were formed. Even after these many decades of use, medical necessity criteria present five issues that still cause grief and need attention for MNC success.
Across the country more and more workers compensation organizations are utilizing Workers Compensation Independent Medical Reviews to keep claims on track, and to decrease unnecessary expenditures as they relate to legal proceedings. When choosing an independent medical review network ask if they offer delegation for workers compensation medical reviews. Delegation provides an opportunity for significantly lower administration expenses wile increasing the quality of reviews.
Understanding and determining medical necessity criteria challenges can be very complex for physicians, clinicians, coders, and billers.
Medical Necessity and Levels of Care (LOC) criteria are interdependent sets of objective and evidence-based health guidelines used to standardize coverage determinations, promote evidence-based practices, and support a patient’s recovery and well-being. Being such, LOC application, documentation, and accuracy plays a pivotal role in care and reimbursement.
Physician Advisors are quickly becoming integral to care review, cost containment, and denial management. Choosing the right model for Physician Advisor Services can be difficult. You want to trust the model and team you choose because the PA services network interacts very closely with your clinical professionals.
Last year, we published a blog about Washington State's IRO Transparency Project. As the ACA evolves into the next phase of healthcare, states continue using tools and resources developed over the past five years. BHM's continues in its role as a leader in IRO services with an update on Washington's project.
Whatever the title, Medical Director, CMO, or similar, the responsibilities loom large with little relief in sight. Burnout, recruitment, and retention might be a larger concern than medical necessity criteria, case shaping, and utilization management. The end of the ACA won't likely make things easier. With that in mind, here are 5 time-saving tips for medical directors.
If you are in the market for an Independent Review Organization (IRO) partner, looking for an IRO that is accredited is a great first step. Accreditation ensures that you receive the highest quality in service and support as well as an IRO who follow strict federal and state regulations. Accredited IROs must comply with important federal and state standards and timelines, ensuring you receive quality support that will help you create efficiencies for your peer review program.
Choosing the right Physician Advisor Services can be difficult. It’s important to look for a Physician Advisor Services that distinguishes itself through quality work, ongoing training, full compliance, and the latest technology. You want to trust the organization you choose and make sure they are industry certified.