Blog Archives

Independent Medical Review (IMR) Hits High In CA

An analysis of the California workers’ comp independent medical review (IMR) process used to resolve medical disputes finds that in 2016, IMR physicians once again upheld about 90% of utilization review (UR) physician’s modifications or denials of treatment, yet IMR volume continued to grow, climbing 6.5% last year.

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Posted in Uncategorized, Utilization Management

AHCA Impact On Payers

The American Health Care Act (AHCA) made its debut. Not many people in government and healthcare industries expect quick passage of the AHCA in its initial form, but understanding the differences with the Affordable Care Act (ACA) sets a framework for how payers prepare for the final version. Fair to say, every organization must make adjustments and the pressures for building internal organization-level efficiencies increase.

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Posted in Trends, Uncategorized

AHCA Impact On Providers

The American Health Care Act (AHCA) made its debut. Not many people in government and healthcare industries expect quick passage of the AHCA in its initial form, but understanding the differences with the Affordable Care Act (ACA) sets a framework for how providers prepare for the final version. Fair to say, every organization must make adjustments and the pressures for building internal organization-level efficiencies increase.

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Posted in Trends, Uncategorized

4 Payer Success Cases vs Opioids

Payer Success Cases focus on tangible and continuous improvements. In January 2017, the healthcare industry saw the release of a white paper…

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Payers’ Big Step For Easing Provider Tension

Easing provider tension begins building trust with payers. A little trust and understanding go a long way towards more efficient payer-provider relationships. One concrete effort, by payers, not only benefits both parties, but builds trust for the long-term.

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Posted in Uncategorized

Medical Director Turnover: Crisis? What Crisis?

Last week, our blog, “Stretching Medical Directors Too Far?” covered the new roles and responsibilities for chief medical officers and medical directors. FULL BLOG. Today’s blog focuses on the financial impact and possible solutions for medical director turnover.

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Doing More With Less: Positive Cost Containment

Positive cost containment can begin with not paying for down time. Administrative resources dedicated to case and claim processing sit on your books as solid, steady expense while the processing pipeline swings dramatically. Paying overtime when backlogs occur will definitely impact the monthly administrative budgets. A number of other factors also contribute to these swings.

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IRO Transparency Project: Summary

IRO Industry Innovation

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.

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Posted in Compliance, Physician Advisor/Peer Review, Population Health, Quality Improvement Programs, Uncategorized

Survey Shows Benefits of Outsourcing Physician Advisor Services

Outsourcing is not a new word for healthcare. The speed of growth of outsourced services is new. Now administrative services joins the ranks of services under outsourcing consideration. A recent survey indicates providers look to outsourcing Physician Advisor complex case review and complex claims review, because they anticipate a decline in reimbursements and inpatient margins narrowing further next year. Almost a 20% growth from 2013 to 2016.

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More Reasons Claims Are Denied: Concordance Rates

What if the peer reviewer is out of sync with medical necessity criteria? How would you know? Looking at concordance rates organized by individual reviewers is one way to review the reviewers performance. Concordance Rates- This rate measures of a Peer Reviewers’ decision to authorize, partially authorize, or deny and compares this decision to the care manager’s belief that the case is not meeting Medical Necessity Criteria for that level of care.

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