Outsourcing Complex Claims and Cases Review

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.

What Is Medical Review: Why Is Vital For Payers And Providers?

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.

Health Insurers Of The Future:
What Are They And How Are They Built?

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.

Checklist for Outsourcing Reviews

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.

Delegation For Workers Compensation

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.

Levels Of Care Coordination

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.

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