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Utilization management programs are often in-house services provided by hospital staff. However, more and more hospitals are outsourcing utilization review management as the pressure mounts to contain costs, especially following the COVID-19 pandemic, and improve care. Hospitals benefit from outsourcing utilization review in several ways, as it can: Free up in-house physician advisors and chief […]
White Papers
The financial impact of the IPO list magnified with the rise of CMS-4201-F, giving rise to inpatient reimbursement for all MAO patients who require services designated on the IPO list. Hospitals need to ensure that the proper setting is scheduled when any Medicare or MA patient undergoes a procedure designated on the IPO list, and they should also follow any proposed additions and removals to the list closely to ensure appropriate treatment and reimbursement.
Case Studies
THE CHALLENGE Hospitals continue to face payer denials throughout the revenue cycle, including technical and administrative denials, as well as coding denials where Diagnostic Related Group (DRG) downgrades are a major pain point. Clinical denials are also rampant, whereby the payers are challenging the clinical judgement of providers despite clear evidence that, for example, inpatient […]