April 17, 2017

Is Price Transparency the Next “Big Thing”? High deductible health plans are likely here to stay. As consumers pay bigger portions for healthcare, many find it difficult, if not impossible, to pay bills that run into the thousands. When consumers can’t pay, physicians and hospitals suffer. Ten US hospitals and health systems filed for bankruptcy […]

April 3, 2017

For the second time, the Centers for Medicare and Medicaid Services (CMS) announced a delay in implementing bundled payment models. CMS’ Interim Final Rule [1] delays several Medicare payment models until Oct. 1, 2017. This rule has stakeholders wondering if there will be yet another delay beyond October or if bundled payments will take hold at […]

March 27, 2017

Hippocrates is often credited as being the first to use some form of the famous quote “First, Do No Harm” which dates back to the late Fifth Century.  This quote was the precursor to today’s modern Hippocratic Oath and was obviously written when physicians weren’t influenced by government reimbursements. With the recent news that the […]

March 13, 2017

Although the rate of appeals is low, mitigating potential and actual conflicts of interest is a critical issue for Independent Review Organizations (IRO). A conflict of interest severely damages the integrity of the independent review process, both for internal and external reviews. Thus, transparency between stakeholders is important to maintain this review integrity. Generally, both […]

March 13, 2017

Drugs are killing us, literally and financially. The Centers for Disease Control (CDC) reports that “opioids (including prescriptions opioids and heroin) killed more than 33,000 people in 2015, more than any year on record. Nearly half of all opioid overdose deaths involve a prescription opioid.”[1] Abuse of tobacco, alcohol and illicit drugs costs our country […]

March 6, 2017

As healthcare organizations continue to transition to value-based care, provider relationships with patients and payers alike will be affected. Value-based care, at its very core, redefines old methodologies and relies on evidence-based outcomes, which is good news for all parties involved. Historically contentious relationships between providers and payers have an opportunity to improve as both […]

February 27, 2017

A Minnesota District Court judge’s ruling “has huge implications for wrongful denial of coverage cases,” and may have long standing implications for the external review industry.[1] The case of James Linn et al. v. BCBSM, Inc., addressed a plaintiff seeking damages against a health plan for its initial refusal to pay for proton-beam radiation therapy […]

February 17, 2017

Genomics and Utilization Management Genetic testing has revolutionized healthcare by providing clinicians with the tools necessary to predict disease.  Sequencing and mapping DNA and other bioinformatics brings huge potential to medicine. Cancer, for example, can be hereditary. Knowing one’s predisposition to cancer could mean the difference between life and death. In the case of Li-Fraumeni […]

February 6, 2017

Should an Independent Reviewer’s Identity be Disclosed? Mention reviewer anonymity and you’ll uncover strong opinions for and against the practice. It’s hard to find a middle ground on the matter of whether to reveal an independent reviewer’s identity. And even though the Centers for Medicare and Medicaid Services (CMS) do not permit insurers to “provide […]

February 3, 2017

Providing Transparency in External Review Transparency in healthcare is an important part of the Affordable Care Act (ACA). And even though ACA will either be dismantled entirely or undergo significant changes with the new administration, it’s likely that transparency will remain a key issue. Additional legislation, including the Mental Health Parity and Addiction Equity Act […]