August 3, 2017

A hallmark of our society is allowing all U.S. citizens to have “their day in court” or fundamental “due process” to make sure their rights are protected. One would hope – even expect – the same would be true when a patient (or their ordering healthcare provider) requests insurance coverage for a life-saving treatment. When […]

August 3, 2017

Utilization Management (UM) appeals allow patients, attending providers, and family members to challenge an adverse determination based on a health plan decision that the care is not medically necessary or clinically appropriate. In instances where there is imminent danger to a patient’s life or limb, an expedited appeal may be necessary. To examine current trends […]

May 11, 2017

The American Society of Clinical Oncology (ASCO) released a statement on April 18, 2017 urging payers not to use utilization management (UM) approaches that would limit cancer patients’ access to high-quality high-value care. The organization asserts “that in modern cancer care there is frequently a lack of interchangeable clinical options, and that optimal cancer care […]

May 2, 2017

Medicaid provides coverage for healthcare services for individuals and families with incomes of up to 138% of the federal poverty level (FPL). The 2017 levels equate to $16,400 per year for individuals and $33,600 for a family of four.[1] But income levels alone won’t qualify people for benefits unless they comply with additional requirements, including […]

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 […]