Mental health services are hard to access in rural America: Telemedicine can help
Posted on November 13, 2017
To say those who live in rural America can have difficulty accessing mental health care, is an understatement. Two such barriers they face are transportation and the scarcity of providers in country settings. These combined issues place burdens on family physicians to provide mental health care when many patients truly need to see a psychiatrist. Appalachia is a region of the country that has [...]
Read more
Telemedicine Medication-Assisted Treatment: A Key Part of Solving the Opioid Epidemic
Posted on November 9, 2017
If you’re reading this, you probably know someone – a family member, friend, or neighbor – who has overdosed from opioids. The President’s Commission on Combating Drug Addiction and the Opioid Crisis paints a grim picture in its Final Report, issued on November 2, 2017: in the U.S., more than 175 lives are lost to addiction every day. There is hope, however, because of the tireless [...]
Read more
Hurricanes Harvey, Irma and Maria Remind Us that Telemedicine Can Help Provide Important Medical Care in Times of Natural Disasters
Posted on September 19, 2017
As Hurricanes Harvey, Irma and Maria brought destruction to the U.S. within a 30-day period, medical professionals rushed in to help of all stripes and colors. In addition to the traditional on-the-ground relief efforts, a growing number of doctors, nurses and others provided care remotely through the phone, video, smartphone apps and other telemedicine modalities. The provision of both emergency [...]
Read more
Understanding the Appeals Process
Posted on 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 a patient does not receive the expected covered care, the [...]
Read more
UM Expedited Appeals
Posted on 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 in this important aspect of [...]
Read more
Hospitals Rein in Drug Costs for Inpatients
Posted on 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 was uncertain [...]
Read more
DARK Daily: Utilization Management of Clinical Laboratory Tests Is Hot Trend as Labs Strive to Demonstrate Value, Get Paid More for Lab Testing Services
Posted on 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 [...]
Read more
ASCO Opposes Payer Utilization Management Approaches that Curb Access to High-Quality, High-Value Cancer Care
Posted on 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 requires patient access [...]
Read more
Work Requirements for Medicaid Gain Popularity Among States
Posted on 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 working, as requested in waivers by some [...]
Read more
Is Price Transparency the Next “Big Thing”?
Posted on 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 in 2016, and five more have done so in the [...]
Read more
CMS Again Delays Bundled Payment Models for Cardio and Ortho
Posted on 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 all under the Trump [...]
Read more
When “Do No Harm” Competes with the Bottom Line
Posted on 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 Mayo Clinic plans to prioritize patients based on [...]
Read more
Keeping External Reviews Free from Conflicts of Interest
Posted on 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 states [...]
Read more
Understanding Parity Laws
Posted on 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 over $700 billion every year, as [...]
Read more
Creating a Win-Win in Utilization Management
Posted on 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 [...]
Read more
Minnesota Ruling Creates Implications for Medical Necessity Decisions
Posted on 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 for the plaintiff’s bone cancer. This [...]
Read more
Genomics and UM
Posted on 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 [...]
Read more
Should an Independent Reviewer's Identity be Disclosed?
Posted on 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 financial incentives to [...]
Read more
Providing Transparency in External Review
Posted on 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 (MHPAEA) also [...]
Read more
California Court Clarifies Reporting Requirement in Independent Medical Review Cases
Posted on July 5, 2016
The Court of Appeal for the Second Appellate District in California has issued an important decision on the reporting requirement for workers’ compensation claims. In the case of California Highway Patrol v. WCAB and Dorothy Margaris, the Court found that a report issued by Maximus in an independent medical review case was still binding even though it was issued 13 days late. The employee, [...]
Read more
Spotlight on Specialty UM Programs: Drug Utilization Review
Posted on May 31, 2016
As the abuse of prescription drugs continues to grow, utilization management practices have proved to be an invaluable tool in the effort to help curb this trend. The Academy of Managed Care Pharmacy (AMCP) defines drug utilization review as “an authorized, structured, ongoing review of prescribing, dispensing and use of medication.”[i]  Patient prescription and medication data is monitored [...]
Read more
CMS Releases New Rule Updating Requirements for Medicaid Managed Care Appeals Procedures
Posted on May 11, 2016
On April 25, the Centers for Medicare and Medicaid Services (CMS) released a final rule on Medicaid and Children’s Health Insurance Plan managed care. The 1,425-page rule contains several important changes to the Medicaid managed care appeals process that will ultimately streamline the appeals process among the different markets. These changes are aimed at making the appeals process more [...]
Read more
California Case may have Huge Impact on UM System
Posted on April 29, 2016
Reviewers issuing decisions on utilization management (UM) appeals would be wise to keep an eye on a court case currently making its way through the California court system. The case, Kirk King v. CompPartners, centers on a workers’ compensation UM appeal decision in which the reviewer concluded that Mr. King’s use of Klonopin was not medically necessary. When a patient stops taking Klonopin, [...]
Read more
UM “Prospective Review” Continues to Demonstrate Value
Posted on April 20, 2016
Since the advent and expansion of utilization management (UM) systems in the 1980’s, many changes and enhancements have been implemented.  Among other changes, many UM programs are now embedded in integrated medical management delivery models that often appear seamless to the patient or ordering provider.  Of course, many of the fundamental tools used in UM interventions are still around, [...]
Read more
Utilization Management Programs Promoting Patient Safety
Posted on April 11, 2016
The evolution of utilization management (UM) interventions continue to open up new ways to promote best practices.  To that end, many health plans, care management organizations and other sponsors of UM programs have begun to focus on promoting emerging “patient safety” protocols even if these add to the over-all costs of paying for insurance. A recent example of this quality-based [...]
Read more
UM Practices in Workers' Compensation
Posted on April 1, 2016
Workers’ compensation programs, as we know them today, have evolved over a 30-year period.  Over time, benefits were standardized, cost-containment and equity with state regulations was addressed, and return to work programs that benefit workers were introduced. As this evolution continues, the need to contain costs continues to be critically important. In 2011, state and federal workers’ [...]
Read more
The Role of Accreditation in Utilization Management
Posted on March 16, 2016
Over the last 30 years, accreditation organizations have assumed an increasingly important role in filling regulatory gaps by establishing quality standards before similar provisions are adopted by states and federal governments. Supporters of private sector accreditation programs note that these nonprofits can work more efficiently create quality standards that fill important gaps in the health [...]
Read more