More Reasons Claims Are Denied: Concordance Rates

2017-04-02T13:27:56-04:00By |Uncategorized|

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.

Why Claims Are Denied: One Doctor’s POV

2017-04-02T13:27:56-04:00By |Uncategorized|

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. Dr. Nicholas Fogelson wrote a perspective article about his experience as a peer reviewer for an independent review organization network and how the lessons apply to practicing providers.

Healthcare Growth in 2017

2017-04-02T13:27:56-04:00By |Uncategorized|

As the last week of 2017 closes, BHM looks forward to helping your organization build and grow in the coming year. In three separate articles, healthcare experts commented on major strategies and trends. Their observations in these specific articles apply to what organizations must do for growth in 2017.

Behavioral Health Case for Payers

2017-12-01T13:26:01-04:00By |Behavioral Health Integration|

“Overnight we became responsible for all outpatient mental health services for our entire patient population,” said Peter Currie, a psychologist and clinical director of behavioral health at the plan. Heading the wrong direction? Here is the unasked question. How will payers and providers build internal behavioral health capacity to meet care demand when there are barely enough to cover the actual care?

Payer-Provider Joint Ventures Gain Steam

2017-04-02T13:27:57-04:00By |Uncategorized|

An article in Managed Healthcare Executive, reports that joint ventures are gaining steam as plans and providers look for ways to work together to provide higher-value care. About 13% of all U.S. health systems offer health plans, covering about 18 million members—or 8% of insured lives. according to a report from McKinsey & Company. Also according to the company, the number of provider-owned health plans is increasing about 6% each year.

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