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