Authors


Rene Moret

Latest:

On Finance: Will managed care physicians see an advantage with the new Medicare Advantage?

With the additional funding, there's a brighter future for MCOs


Nancy Paddison

Latest:

Health plans can stay ahead of market curve with CRM

Developing preferred relationships with members leads to increased market share for payers


Elaine Zablocki

Latest:

Insomnia symptoms can indicate underlying medical conditions

Symptoms of insomnia can be treated with several different drugs, but be aware of side effects.


Stuart R. Kaplan

Latest:

MCOs saddled with legal struggles when forming physician networks

Conflicting interests cause disputes over fairness, contracts and liability with MCOs stuck in the middle


Wendy M. Novicoff, PhD

Latest:

Six Sigma enters the healthcare mainstream

What do you do when you have exhausted all options for improving performance in an environment that is determined to protect the status quo? What do you do when your organization has reached the presumed limit of potential performance and has grown all too comfortable with its market lead?


Joel V. Brill, MD

Latest:

Choose your battles when resources are scarce

In America, we assume that we get what we pay for, whether it be food, clothing or healthcare. Given that healthcare consumes 16% of the Gross Domestic Product and we spend more per capita than any other nation on cutting-edge care, we expect improved outcomes and more bang for the buck. However, these expenditures do not rank the United States first, second or even third in terms of life expectancy, infant mortality, immunization, cancer screening and the like.


Martin I. Kalish, MD, JD

Latest:

Traveling abroad for treatment can be perilous

In an attempt to reduce healthcare costs, a U.S. company is encouraging its employees to go abroad for necessary medical or surgical care. A recent article in the Christian Science Monitor noted that Blue Ridge Paper Products in North Carolina is sending an employee to India for two surgeries that will cost about $20,000-far less than the estimated $100,000 for comparable procedures in the United States.


Dennis A. Robbins, PhD, MPH

Latest:

Choose your battles when resources are scarce

In America, we assume that we get what we pay for, whether it be food, clothing or healthcare. Given that healthcare consumes 16% of the Gross Domestic Product and we spend more per capita than any other nation on cutting-edge care, we expect improved outcomes and more bang for the buck. However, these expenditures do not rank the United States first, second or even third in terms of life expectancy, infant mortality, immunization, cancer screening and the like.


Robert Salcido

Latest:

False Claims Act proves difficult to fight

The federal False Claims Act (FCA) is the government's primary weapon to combat fraud. It empowers the federal government to file actions against those alleged to have knowingly submitted false or fraudulent claims to the government. Since 1986, the Department of Justice has recovered more than $15 billion under the law.


Yvette Schmitter

Latest:

National Provider Identifier: Leveraging regulation to improve health plan operational efficiencies

The administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) require the Department of Health and Human Services (HHS) to establish national standards for electronic healthcare transactions. This includes assigning healthcare providers a National Provider Identifier (NPI), a 10-digit numeric provider identifier that will be used in standard electronic transactions, such as healthcare claims. As of a legislated date of May 23, 2007, each participating provider will have one and only one NPI, regardless of practice locations or settings.


Albert Ghafari

Latest:

National Provider Identifier: Leveraging regulation to improve health plan operational efficiencies

The administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) require the Department of Health and Human Services (HHS) to establish national standards for electronic healthcare transactions. This includes assigning healthcare providers a National Provider Identifier (NPI), a 10-digit numeric provider identifier that will be used in standard electronic transactions, such as healthcare claims. As of a legislated date of May 23, 2007, each participating provider will have one and only one NPI, regardless of practice locations or settings.


James Brock

Latest:

National Provider Identifier: Leveraging regulation to improve health plan operational efficiencies

The administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) require the Department of Health and Human Services (HHS) to establish national standards for electronic healthcare transactions. This includes assigning healthcare providers a National Provider Identifier (NPI), a 10-digit numeric provider identifier that will be used in standard electronic transactions, such as healthcare claims. As of a legislated date of May 23, 2007, each participating provider will have one and only one NPI, regardless of practice locations or settings.


Curtis Brown

Latest:

Arbitration resolves billing disputes without costly litigation

With Administrative costs accounting for as much as 40% of all healthcare dollars spent, many states are seeking new and innovative ways to eliminate bureaucracy and red tape. One area receiving more attention is the resolution of billing disputes between providers and payers. In 2006, New Jersey and California implemented arbitration programs to resolve the growing aggregation of healthcare payment disputes.


Dennis Triplett

Latest:

HSAs welcome credit and convenience

When health savings accounts (HSAs) are attached to high-deductible health plans, employers find the accounts' low cost and high employee accountability attractive. They can bring in lower health insurance premiums, reduce payroll taxes and, for employees, serve as tax incentives and an additional source of retirement savings.


Peter R. Kongstvedt, MD

Latest:

Technology a central factor among interrelated challenges

The most significant pressures facing payers evolve constantly, though they rarely change radically from year to year. While payers strive to lower administrative costs and improve efficiencies, manage healthcare costs and grow the business, recent years have seen substantial change in how they address these issues.


Michael McCue

Latest:

Hospice patients could benefit if referred sooner

Discussing hospice and palliative care with patients and families lowers healthcare costs and allows patients to realize maximum benefits of care


Emad Rizk

Latest:

Downshifting Risk Through Payer-Provider Partnerships on the Road to Value-Based Care

COVID-19 forced providers and health plans to hit the brakes on traditional approaches to managing care—and then continue the journey in another vehicle, at a pace that seemed to approach 100 miles per hour.


Barry Senterfitt

Latest:

Review health risk assessment use under new GINA rules

Financial incentives and penalties are no longer permitted when genetic information is requested on health risk assessments


Alex Gilderman

Latest:

Medication management not well defined in MMA

Medication therapy management (MTM) has long been a part of the pharmacy lexicon and is based on the premise that the right medication in the right dose gets to the right patient. This is to ensure that optimal outcomes are achieved with the highest safety. Numerous examples of pharmacy programs in diverse settings utilize the skills of the pharmacist to optimize drug therapy and improve outcomes and assure safety. The Veterans Administration, academia, health plans, as well as community pharmacies have all been settings where medication management of the patient has occurred.


Tom Morrison

Latest:

Physician connectivity reduces workload

Physicians connected to health plans deliver better care, enjoy faster reimbursements, and have a lighter administrative load


Robert A. Sharp

Latest:

Management 101, Part 1

What kind of executive are you? Take the test.


John H. Capobianco

Latest:

More efficient transactions lead to better collaboration with providers

Automation and integration are the keys to better care


Jonathan P. Gertler

Latest:

On Finance: Endovascular abdominal aortic aneurysm repair

Quality and economic drivers for a new technology adoption


Tim Dickman

Latest:

Carve-in strategy adds context to integrated pharmacy investment

In-house pharmacy management empowers members to control their spending


Richard Robinson

Latest:

Beef up your vendor's security measures to avoid a breach in patient privacy

Ask hard-hitting questions about data security, backup and recovery when outsourcing IT functions


Steve Tiffany

Latest:

Beef up your vendor's security measures to avoid a breach in patient privacy

Ask hard-hitting questions about data security, backup and recovery when outsourcing IT functions


Dr. David Young

Latest:

Improved OR management alleviates common frustrations

Providers and payers benefit from efficient scheduling,vbalanced utilization and adequate staffing


Dr. William Mazzei

Latest:

Improved OR management alleviates common frustrations

Providers and payers benefit from efficient scheduling,vbalanced utilization and adequate staffing


Marilyn Ellicott

Latest:

Planning can help home health agencies thrive in the era of P4P

Pay-for-Performance (P4P) provides home health agencies an opportunity to show their value and expertise to the healthcare industry. The primary goal of home health has always been to educate the client and family on how to proactively manage a chronic illness and avoid the reoccurrence of an acute illness. Home health nurses are the eyes and ears of the physician, often recommending modifications to the plan of care based on their knowledge of the patient's medical condition and home environment. With the advancement of healthcare technologies and pending P4P regulations, this knowledge becomes a more important basis for assessing patient and family compliance to care recommendations.


Robert W. McCann

Latest:

Legality of California's pay or play law called into question

Uninsured workers need coverage, but opponeents say law is preemted by ERISA

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