|Editor’s Note: Engaging BHM for peer review and physician advisory services for following medical necessity criteria review uncovers surprising benefits. To learn more about leveraging the value of Peer Review and Physician Advisory services click HERE.|
Using a 3rd party, unbiased, independent peer review partner to follow medical necessity criteria and make determinations builds trust, increases engagement, and improves system relationships. Understanding why claims are denied, from a doctor’s point of view, opens the discussions on the benefits of simple changes on payers and providers.
Dr. Nicholas Fogelson wrote a perspective article for KevinMD.com. He wrote about his experience as a peer reviewer for an independent review organization network. The observations hit to the heart of why third-party peer review (for payers) and physician advisor services (for providers) are vital for building efficiencies.
“There is a near-unlimited amount of medical care that could potentially be delivered for patients in this country, but the amount of funds is relatively fixed. As such, it is absolutely imperative that there is some system of rationing involved that will work towards using those limited funds where they will be most useful. Weeding out requests for therapies that are medically unnecessary or unproven is part of that.” – Dr. Fogelson
The list below summarizes Dr. Fogelson’s experiences and observations. These represent his unsolicited point of view only, and are included to illustrate the impact of independent reviews cases and claims.
- Poor documentation. Of every 10 charts Dr. Fogelson reviewed, on average 6 were rejected because the physician did not accurately document what they were doing and why they were doing it.
- Full-spectrum medicine. Of every 10 charts Dr. Fogelson reviewed, on average at least 3 the physician suggested a care plan outside of medical necessity criteria or did not have a foundation in evidence-based research.
- Industry acceptance of something that cannot be supported in the literature or not evidence-based.
- Industry introduction of new technology that has yet to be adequately studied. Dr. Fogelson believes it is common for some industry organizations to try to get their new technology adopted before extensive evidence-based research bears out efficacy.
- Failure to attempt reasonable treatments that are less expensive prior to going to expensive treatments.
Why Claims Are Denied
The takeaway lessons, from Dr. Fogelson’s observations, point to two very fixable inefficiencies: better documentation and following evidence-based research for care.
Third-party peer review and physician advisory services from BHM Healthcare Solutions systematically addresses these opportunities for both payers and providers.
For providers, case review shapes the completeness of the patient reviews; making recommendations, based on medical necessity criteria, for additional documentation before wasting claims processing time.
For payers, the independent review demonstrates impartiality and encourages cooperation between payer and provider when working towards efficient patient care. The movement to value-based patient care systems need very high levels of cooperation and impartiality.
Engaging BHM for peer review and physician advisory services for following medical necessity criteria review uncovers surprising benefits. To learn more about leveraging the value of Peer Review and Physician Advisor services click HERE. Why Claims Are Denied