The promises of value-based payment models came to life within the last 12+ months with results of real world tests. They quickly move to the implementation of useful models and processes. With ramped-up implementations overcoming value-based care barriers step out as real things.
Responding to unreasonable hurdles for patients seeking care, a coalition including the American Medical Association (AMA) and 16 other health care organizations today urged health plans, benefit managers and others to propose prior authorization reform requirements imposed on medical tests, procedures, devices, and drugs.
Both payers and providers cannot find enough specialized talent for reviewing complex cases and claims, especially, behavioral health care. This unfortunately leads to in-house staff making decisions and hoping the decisions stick. Revenue processes need razor-thin efficiency in this new age of healthcare and using experienced personnel for making high risk decisions makes the most of your resources.
Medical review is the collection of information and clinical review of medical records by physician advisors (for providers reviewing cases before submissions) or a peer review team (for payers) to ensure that payment is made only for services that meet coverage, coding, and medical necessity requirements. Here are 10 instances which can help you better identify when its time to look for a partner.
PwC’s Health Research Institute (HRI) released the results from a post-election survey focusing on models of health insurers of the future and the expectations of future members. The results and impacts outlined in their website report, identifies missions and investments for organizations best suited for targeted populations. Here are 10 instances which can help you better identify when its time to look for a partner.
Many payers and providers look to independent review organizations (IROs) as first-tier entities to gain efficiencies with decision-making and for an outside perspective on case documentation, utilization, and levels of care. So how do you know when it's time to start working with an IRO? Here are 10 instances which can help you better identify when its time to look for a partner.
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.