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.
Level of Care Guidelines are usually derived from generally accepted standards of behavioral health practice. These standards include guidelines and consensus statements produced by professional specialty societies, as well as guidance from governmental sources such as CMS’ National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).
Analyzing your revenue cycle from start to finish can lead to recouping significant revenue dollars for your organization. Knowing what are the most impactful metrics sets revenue cycle experts apart.
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.
Many hospitals are currently asking themselves, "How can we improve our revenue cycle in 2015?" This topic is also one many C-suite executives are facing in 2015, which is proving to be another year of vast changes. Financial departments will have to stay on top of contract management, as well as planning for shifts in how payments are received. Today, we've put together a list of 5 ways healthcare providers can reboot their revenue cycles and stay ahead of those changes that impact the bottom line.
Any serious discussion of patient care and cost containment must include a discussion about utilization review and management. Sometimes these two terms are used interchangeably, while their meanings and processes are quite different in reality.
Understanding and determining medical necessity criteria challenges can be very complex for physicians, clinicians, coders, and billers.