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 […]

July 31, 2017

Hospitals Rein in Drug Costs for Inpatients As drug prices rise, hospitals double down on tried-and-true pharmacy management strategies By: Maggie Van Dyke  June 7, 2017 When Cleveland Clinic launched an initiative to control drug costs, Jeff Rosner, senior director of pharmacy contracting and purchasing, was skeptical. Knowing the pharmaceutical marketplace as he did, he […]

June 26, 2017

DARK Daily: Utilization Management of Clinical Laboratory Tests Is Hot Trend as Labs Strive to Demonstrate Value, Get Paid More for Lab Testing Services June 21, 2017 08:00 AM Eastern Daylight Time AUSTIN, Texas–(BUSINESS WIRE)–To offset decreased lab budgets and shrinking payments from health insurers, the nation’s best-performing hospital and health system clinical laboratories are […]

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 […]