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Prenatal ultrasound gathering momentum in disease managementFor more than three decades, clinicians have routinely conducted prenatal ultrasound screenings to detect congenital anomalies, multiple-gestation pregnancies, fetal growth disorders, placental abnormalities and errors in the estimation of gestational age. When managed care was born, executives realized the importance of providing benefit coverage for this test because they recognized prenatal ultrasound is one of the earliest tools in the disease management arsenal to promote fetal, neonatal, and maternal health. In an era where medical costs are surging, and in response, healthcare premiums of employers and their workers have climbed twice as fast as wages and inflation in 2006, the evidence-based benefits of prenatal ultrasound is gaining momentum and medical community recognition as a disease management tool.
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Administrative tasks simplified: Electronic transmission saves time, moneyThere is no doubt about it-transmitting claims and other healthcare information electronically saves time and money.
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False Claims Act looms for healthcare regulationThe False Claims Act (FCA), 31 U.S.C. 3729, et seq., is about to become the worst-kept secret of the healthcare industry. One of the nation's oldest statutes, the FCA has allowed the government to recover more than $3.1 billion in the first nine months of 2006, including an eye-popping $900 million dollar settlement with Tenet Healthcare-the largest FCA recovery ever. And, as if these staggering numbers were not enough to garner attention, as of January 1, 2006, entities that receive $5 million or more per year in Medicaid payments will be required to inform their employees about the FCA. Because employees are the most likely whistleblowers in an FCA lawsuit, the FCA's prominence in the healthcare industry should increase over the next few years.
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False Claims Act looms for healthcare regulationThe False Claims Act (FCA), 31 U.S.C. 3729, et seq., is about to become the worst-kept secret of the healthcare industry. One of the nation's oldest statutes, the FCA has allowed the government to recover more than $3.1 billion in the first nine months of 2006, including an eye-popping $900 million dollar settlement with Tenet Healthcare-the largest FCA recovery ever. And, as if these staggering numbers were not enough to garner attention, as of January 1, 2006, entities that receive $5 million or more per year in Medicaid payments will be required to inform their employees about the FCA. Because employees are the most likely whistleblowers in an FCA lawsuit, the FCA's prominence in the healthcare industry should increase over the next few years.
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EHRs not sufficient for data liquidityAn EHR is one technology within the health IT portfolio, which also includes e-prescribing, clinical decision support, messaging and alerting, telehealth, consumer health information portals and other technologies
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Small data creates backbone for medical homesMedical home providers gain tailored prescription data
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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
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Health plans can stay ahead of market curve with CRMDeveloping preferred relationships with members leads to increased market share for payers
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Insomnia symptoms can indicate underlying medical conditionsSymptoms of insomnia can be treated with several different drugs, but be aware of side effects.
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MCOs saddled with legal struggles when forming physician networksConflicting interests cause disputes over fairness, contracts and liability with MCOs stuck in the middle
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Six Sigma enters the healthcare mainstreamWhat 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?
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Choose your battles when resources are scarceIn 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.
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Traveling abroad for treatment can be perilousIn 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.
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Choose your battles when resources are scarceIn 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.
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False Claims Act proves difficult to fightThe 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.
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National Provider Identifier: Leveraging regulation to improve health plan operational efficienciesThe 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.
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National Provider Identifier: Leveraging regulation to improve health plan operational efficienciesThe 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.
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National Provider Identifier: Leveraging regulation to improve health plan operational efficienciesThe 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.
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Arbitration resolves billing disputes without costly litigationWith 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.
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HSAs welcome credit and convenienceWhen 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.
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Technology a central factor among interrelated challengesThe 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.
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Hospice patients could benefit if referred soonerDiscussing hospice and palliative care with patients and families lowers healthcare costs and allows patients to realize maximum benefits of care
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Downshifting Risk Through Payer-Provider Partnerships on the Road to Value-Based CareCOVID-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.
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Review health risk assessment use under new GINA rulesFinancial incentives and penalties are no longer permitted when genetic information is requested on health risk assessments
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Medication management not well defined in MMAMedication 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.
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Physician connectivity reduces workloadPhysicians connected to health plans deliver better care, enjoy faster reimbursements, and have a lighter administrative load
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More efficient transactions lead to better collaboration with providersAutomation and integration are the keys to better care
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On Finance: Endovascular abdominal aortic aneurysm repairQuality and economic drivers for a new technology adoption
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Carve-in strategy adds context to integrated pharmacy investmentIn-house pharmacy management empowers members to control their spending
