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.
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.
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.
Is California blazing a trail with their recent session's addressing utilization review reform? Will the other states follow in their steps and how quickly?
Physician Advisors are quickly becoming integral to care review, cost containment, and denial management. Choosing the right model for Physician Advisor Services can be difficult. You want to trust the model and team you choose because the PA services network interacts very closely with your clinical professionals.
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.
Whatever the title, Medical Director, CMO, or similar, the responsibilities loom large with little relief in sight. Burnout, recruitment, and retention might be a larger concern than medical necessity criteria, case shaping, and utilization management. The end of the ACA won't likely make things easier. With that in mind, here are 5 time-saving tips for medical directors.
Healthcare's landscape changes constantly, including the practice standards agreed to by their industries. URAC and NCQA offer a range of credentials for organizations which appear in more and more state laws and payer/provider contracts. Staying current with the latest policies means a full-time effort.
As the ACA Repeal and Replace process sets a new course for healthcare, now is the time for reviewing a quick list of Health Plan Best Practices. The ACA mandated external review options for all consumers. Continuing this service to consumers sends a positive message about their health plan choice.