Social Determinants: Payer Cases Improving Member Health

Currently, payer strategies focus on finding healthy populations, segmenting the markets, and segmenting populations, with the target of avoiding costly procedures. Population management and all the big data trends became useful tools in those payer strategies. With the results from a study by the Robert Wood Johnson Foundation and a position paper by America's Health Insurance Plans (AHIP), social determinants quickly rose as the next measurable data used by payers.

Challenges of Developing Workers Compensation Treatment Guidelines

Workers compensation treatment guidelines can help prevent unnecessary medical procedures and the prescribing of potentially harmful medications. However, they are not all the same, nor are they without challenges. Understanding a jurisdiction's strengths/weaknesses, taking a strategic approach to developing guidelines, and using common sense can lead to better outcomes for injured workers—and, ultimately, lower costs for payers.

1 Day Left to Sign up For BHM’s Free WebClinic “Components of a Great Peer Review Program”

BHM's webclinic “Components of a Great Peer Review Program” goes live Wednesday, November 18th from 12:00pm to 1:00pm EST. You don't want to miss this great opportunity to receive expert advice related to Peer Review Services. Don't worry you still have time to sign up!

5 Key Elements of the Peer Review Process

Lately we have been talking about the important of Independent Review Organizations (IROs) and peer reviews in the healthcare ecosystem. Today we continue this discussion and delve deep into the importance of the peer review process. We know that peer reviews are a crucial part of healthcare because they hold medical professionals and organizations accountable in addition helping to build a world of trust between patient and physician. The peer review process is one that consists of high levels of property technology and superior customer service. By boosting transparency in healthcare, peer reviews have become an essential standard helping to make healthcare safer and more efficient. So let’s take a look at the 5 core building blocks of the peer review process.

IROs and Objectivity

Healthcare costs have long been the subject of heated debates. But thanks to Independent Review Organizations (IROs) both providers and members are finding common ground. Objectivity is the name of the game when it comes to reviewing medical necessity claims, and IROs help keep resources properly allocated within health systems by acting as an outside opinion on complex claims.

Utilization Review vs Utilization Management: The Difference

Defining the Difference: Utilization Review vs. Utilization Management Sometimes these two terms are used interchangeably, while their meanings and processes are quite different in reality. This duality can lead to confusion, so today, we wanted to take the time to explain the difference between these two types of services and outline their unique benefits in the healthcare continuum.

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