Medical review is the collection of information and clinical review of medical records by physician advisors (for providers reviewing cases before submissions) or a peer review team (for payers) to ensure that payment is made only for services that meet coverage, coding, and medical necessity requirements. Here are 10 instances which can help you better identify when its time to look for a partner.
PwC’s Health Research Institute (HRI) released the results from a post-election survey focusing on models of health insurers of the future and the expectations of future members. The results and impacts outlined in their website report, identifies missions and investments for organizations best suited for targeted populations. Here are 10 instances which can help you better identify when its time to look for a partner.
Many payers and providers look to independent review organizations (IROs) as first-tier entities to gain efficiencies with decision-making and for an outside perspective on case documentation, utilization, and levels of care. So how do you know when it's time to start working with an IRO? Here are 10 instances which can help you better identify when its time to look for a partner.
You know your reimbursement process needs attention when the response to an adverse determination is to resend the exact same paperwork through the pipeline. In a few cases, the ROI on a resend appears reasonable, but peel back the band-aid and you will find a process needing attention. Understanding data management is denial management begins the healing process.
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.
The Centers for Medicare & Medicaid Services released the final version of its hospital quality ratings Wednesday and posted them to the Hospital Compare website. Many of the most well-known hospitals in the nation received below average scores while lesser known facilities took the top scores.
Thanks to The Excellence in Mental Health Act (ExACT) passed in 2014, it’s predicted that 2016 will be a big year for Behavioral Health. As the country takes critical steps towards moving Behavioral healthcare off the back burner, demand for these services continues to grow. This will result in ample opportunity for organizations diving into Behavioral Health or BH Integration to champion the cause in 2016. But it’s important to remember that the impact of Behavioral health moves across the care continuum.
The Centers for Medicare & Medicaid Services released the final version of its hospital quality ratings Wednesday and posted them to the Hospital Compare website. Many of the most well-known hospitals in the nation received below average scores while lesser known facilities took the top scores.
Patient Centered Medical Homes (PCMH) value based care model growing across the United States. PCMHs aren’t actually places but care models based on providing care which is accessible, coordinated, and comprehensive. PCMHs focus on patient centered care and are committed to quality and safety.
According to the Centers for Disease Control, an estimated $25 billion of U.S. healthcare costs was attributed to the abuse of painkillers—otherwise known as opioids. Up to 36 million people worldwide struggle with opioid addiction. CNN recently revealed that health Insurance companies alone lose a total of $72.5 billion annually due to of opioid addiction. Cigna is the most recent health insurance company to join the fight. By using patient data they are hoping to target overprescribing of prescription painkillers. Monitoring patient data and prescription history Cigna flags high-risk customers and notifies doctors about the patient’s history of opioid use or their high-risk behavior which puts the patient at risk for new prescriptions.