The Payer's Edge
With the new federal healthcare reform laws, healthcare payer and medical management organizations expect to process about 32 million new enrollees during the next 10 years, dramatically increasing the volume of utilization reviews for complex and critical care services. As a result of this increased volume, the outsourcing of first-level physician review will become more important than ever.
Outsourcing first-level physician review has become essential as health plans continue to face increased pressure to handle larger volumes while controlling cost. When making the decision to outsource, health plan executives must weigh both the advantages and disadvantages of moving their medical reviews to an external partner. Let’s take a look at the pros and cons of outsourcing medical reviews for payer organizations.
Hepatitis C is an infectious disease caused by the hepatitis C virus (HCV), which attacks the liver and leads to inflammation. It is important to recognize the transmission and risk factors associated with HCV as well as the conditions linked to the disease to facilitate early diagnosis and treatment.
Sending your medical reviews to an Independent Review Organization offers many benefits, including faster turnaround time and a broader depth of specialty knowledge. Once you have made the decision to send your medical reviews it is important that you understand how to get the best results from these reviews and what factors will impact the determination. Read on to learn three tips to getting the best results from your outsourced reviews.
Lumbar fusion is a common and very beneficial procedure. Learn which conditions are indicators for this procedure and which conditions do not respond well to fusion and should be managed with non-operative care.
Due to the increasing incidence of diabetes, more and more health plans are dealing with determinations of coverage for patients suffering from the condition. Learn more about determining medical necessity and how to use independent review to achieve high-quality defensible determinations for these cases.
The management and treatment of diabetes is a growing concern as more Americans are diagnosed each year. The American Diabetes Association has laid out standards of care for patients suffering from this condition which must be taken into account in the development of any treatment plan. Take a closer look at these standards of care as they pertain to both self-monitoring blood glucose and continuous glucose monitoring.
Effective care for patients requires an in-depth understanding of the continually evolving prenatal screening and diagnostic testing modalities. Learn more about the screen and diagnostic procedures and there proper use in each trimester.
The American College of Obstetricians and Gynecologists (ACOG) has set out a number of guidelines for screening for fetal aneuploidy and prenatal diagnostic testing for genetic disorders. Gain a better understanding of these guidelines and how they can be used in making high-quality defensible coverage determination.
Prenatal Screening & Diagnostic Testing: Indications, Risks, Medical Necessity, and Independent Review
Prenatal screening and diagnostic testing are vital tools in effective prenatal care. Learn more about the indications, risks involved, and how to determine medical necessity for these procedures as well as how to use independent medical review to enhance patient care and achieve high-quality, defensible determinations.
MedCert: Meeting the Needs Driven by the Mental Health Parity and Addiction Equity Act and the Affordable Care Act
Along with the growing incidence of mental health and substance abuse problems in the United States, the Mental Health Parity and Addiction Equity Act and the Affordable Care Act are driving the growing number of behavioral/mental health determinations being dealt with by payers. Learn more about the effect these changing regulations have had and how AllMed's MedCert can help meet the needs of payers with a first-level pre-authorization solution.
Mental health and substance abuse problems are a growing concern. Because of the expanding number of claims payers are seeing in these areas, the need for a first-level preauthorization medical review solution to bridge the gap has become vital. Learn the drivers behind the expanding number of behavioral and mental health claims and how AllMed’s MedCert Solution is bridging the gap.
In today's ever-changing health care landscape, the role and responsibilities of Medical Directors have been stretched beyond the traditional clinical scope. As the scope and complexity of their roles continue to evolve, payers of all types are increasingly partnering with IROs to perform medical review at all stages of the care management continuum. Learn more about how IROs are helping to streamline the utilization review process, easing pressure on medical directors while allowing organizations to work more effectively and efficiently.
The role of Medical Director is one that has evolved over the past decades; requiring M.D.’s to assume greater and greater levels of responsibilities, leading to burnout and a high turnover rate for both provider and payer organizations -a problem accelerated in the era of health care reform. The answer for many has been partnering with an accredited independent review organization (IRO). Take a closer look at the evolving role of medical directors, and its impact on provider and payer organizations.