With the additional funding, there's a brighter future for MCOs
Developing preferred relationships with members leads to increased market share for payers
Symptoms of insomnia can be treated with several different drugs, but be aware of side effects.
Conflicting interests cause disputes over fairness, contracts and liability with MCOs stuck in the middle
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?
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Discussing hospice and palliative care with patients and families lowers healthcare costs and allows patients to realize maximum benefits of 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.
Financial incentives and penalties are no longer permitted when genetic information is requested on health risk assessments
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.
Physicians connected to health plans deliver better care, enjoy faster reimbursements, and have a lighter administrative load
Automation and integration are the keys to better care
Quality and economic drivers for a new technology adoption
In-house pharmacy management empowers members to control their spending
Ask hard-hitting questions about data security, backup and recovery when outsourcing IT functions
Ask hard-hitting questions about data security, backup and recovery when outsourcing IT functions
Providers and payers benefit from efficient scheduling,vbalanced utilization and adequate staffing
Providers and payers benefit from efficient scheduling,vbalanced utilization and adequate staffing
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.
Uninsured workers need coverage, but opponeents say law is preemted by ERISA