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.

concordance ratesOne of our recent blogs recounted the experiences of a doctor who participated as a peer reviewer for an independent review organization network. He estimated 80% of his adverse determinations came from bad or incomplete documentation and provider’s misalignment with medical necessity criteria (MNC). Concordance Rates

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.

  • These rates should be reported on a weekly, monthly, quarterly, and yearly basis.
  • Tracking should occur by provider, case manager, and peer reviewer
  • For example: When a case is sent for peer review and the peer reviewer agrees with the care manager all the time = 100% concordance

This measurement gives you an idea of the performance of the Care Management Team, the Peer Review Team, and the Provider Community. If concordance is very different in any one of these groups it is an indication that something is amiss with the individual’s understand of MNC.

Concordance Rates Example

If a reviewer misses the MNC targets by 30%, then take the number of claims they process. Using the 30% and the number of cases, calculate the potential number of cases that may lead to an appeal that could be avoided if the reviewer were only 5% off the concordance rate target? 5, 10, 20 cases a month or more may be inappropriately processed because of  a misunderstanding. A small amount of training will save significant amount of time, effort, and appeals processing expenses. Think about the expenses saved for each avoided appeal.

Concordance rate savings also apply for providers when they use physician advisory reviewers. Saving a percentage point or two on expenses for the cost of a conversation about understanding the MNC presents a great ROI.

Managing your case data more effectively will reduce costs, improve productivity, and maximize your resources. Can you quickly access your reviewer data and

  • Use Concordance Rates for improving performance
  • Peel away Concordance Rates and target outliers
  • Analyze case review trends by department, reviewer, and case/care managers
  • Focus on process improvements for submission of documentation
  • Build real time trend data for quick analysis
  • See red flags needing corrective actions during periodic performance meetings

BHM is at the forefront of data mining allowing clients to do a deeper dive on case data. Unlike any other reporting tool in the market today, BHM’s peer review system facilitates more data capture, data mining – analysis, reporting and review. Managing your case data more effectively will reduce costs, improve productivity, and maximize your resources.

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.