Blog

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 […]

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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 […]

California
conflict of interest
independent review organization
IRO
mitigate
model act
NAIC
NAIRO
New York
Washington
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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 […]

addiction
CDC
death
mental health
MHPAEA
NIDA
opioid
parity
Patrick Kennedy
substance abuse
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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 […]

evidence-based medicine
McKesson
UM
utilization management
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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 […]

adverse determination
cancer
court
ER
experimental treatment
external review
lawsuit
litigation
MAXIMUS
medical necessity
Minnesota
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