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.
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 the difference between Utilization Review and Utilization Management is very critical in the healthcare continuum. While the two terms often feel interchangeable, in reality their processes and meanings actually are very different. Their differences make all the difference for improving care.
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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.
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.
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.
As 2014 draws to a close, many of us in the healthcare industry are looking back at the year we’ve had and reflect on what worked, what needs to change and what we can expect for 2015. As an industry, healthcare saw a continued move towards accountable care, shared decision making, value-based purchasing and patient satisfaction measures. Buzzwords abound, there was a lot for everyone - providers, patients and payers - to juggle this year. And it looks like the trend is apt to continue into 2015.
The Affordable Care Act will allow 30-40 million new patients to have access to hospital services - particularly emergency room services. ERs are already notoriously overrun and patient dissatisfaction about wait times and care quality are abound. With even more patients expected to grace the department than ever before, how can your ED prepare?
One of the many ways in which healthcare organizations are assessed these days is both internal and external in the form of utilization review. Internally, there are reviews done by designated staff members (who are usually nurses) who keep tabs daily on the patient care measures set forth by a hospital as tracking measures. They are reviewing the care of inpatients on any given day, trying to look for trouble spots before they become problematic. If a major event occurs within the hospital regarding patient care, an external review will need to done to help determine any disciplinary action, workflow changes or protocol alterations that might be necessary to keep it from recurring.