Solving Quality of Care Problems In Large Hospital Chains

At AllMed Healthcare Management, we’re proud to be working with some of the largest hospital chains in the United states to improve their quality of care by providing outsourced hospital peer review services. Two of the largest chains are very good customers of ours and have sent dozens of their hospital peer reviews to us in order to resolve issues of bad outcomes and sentinel events. The directors and vice presidents of medical affairs and quality management at the headquarters of these organizations are delighted with the work that we’re doing for their organizations and as a result they continue to reward us by increasing the number of cases that they’re sending us for hospital peer review. Each year, we’ve also conducted an annual customer satisfaction survey that shows that well over 75 percent of our clients are either extremely satisfied or satisfied with the quality, timeliness and the turnaround time of our services. We continue to conduct customer satisfaction surveys to stay close to our customers, making sure that they’re satisfied with the services that we’re providing to them.

Independent Review Organizations & The Appeals Process

Every healthcare organization has different policies and procedures relating to the handling of healthcare appeals or appeals of adverse determinations. While state and federal regulations dictate in large part how these appeals are handled, each healthcare payer has much leeway in determining exactly how to deal with them. Many companies have first-level appeals or second-level appeals that are done inside their own organization and use the IRO as a third-level appeals entity. Other healthcare payers actually send all of their appeals directly out to IROs immediately as their first-level response. Some payers use the IRO’s determination as binding upon their decision making process as a matter of best practice. Other health insurance payers consider the IRO independent medical review to be another input to the decision making process but reserve the right to make a final determination in house.

So, health plans use IROs differently to satisfy regulatory requirements. IROs represent a very flexible approach capable of being used and deployed no matter what the healthcare payers’ internal process may look like. We have clients that perform some first-level appeals internally and others automatically send those same types of cases from the same health plans out to us. This level of flexibility and adaptation on the part of the independent review organization is what makes IROs so appealing to health insurance payers: They can be flexibly deployed around just about any type of process both internal and external.

External appeals and external reviews by IROs are a part of many state insurance commissioners’ appeals processes. In almost all states, state insurance commissioner organizations have set up processes whereby any patient who has been denied a benefit by their health plan and has gone through an appeal can then appeal to the state insurance commissioner. The state insurance commissioners have set up panels of independent review organizations to process those requests from patients. The IROs render independent medical review determinations and responds directly to address any concerns that patients might have directly to them.

This consumer advocacy element is an important part of the checks and balances that we have in our health care system. For example, it assures that people who are paying for insurance coverage indeed get what they’re supposed to receive while, at the same time, assuring that people who are covered under insurance but are receiving unnecessary treatments outside of the standard of care are denied those treatments. By denying treatments that are unnecessary, the healthcare system assures that more resources can be allocated towards those who deserve them. Independent review organizations serve an important part of the external appeals process with health insurance payers.

How A Hospital Can Improve Its Standards Of Care

If you’re a hospital organization that’s looking to reduce the number of sentinel events and bad outcomes and improve patient safety and healthcare quality, consider outsourcing your peer review process to an independent review organization. An independent review organization can speed up the peer review process, identify poor performance in a rapid and objective manner, and give you key feedback on explain how to move forward with corrective action in different departments of your hospital at a relatively low cost.

For this reason, hospitals that are looking to improve their healthcare quality are adopting the best practice of hospital peer review using an outsourced independent review organization. Using an IRO helps reduce litigation, potential negative press, class action lawsuits and other punitive measures that can be the result of not solving misdiagnosis and mistreatments inside their hospitals. As a risk manager or a director of clinical quality care, can you afford not to be looking at ways to continuously improve the quality of your care and patient safety?

These are mandated activities by JCAHO (Joint Commission on Accreditation of Healthcare Organizations) and certainly activities that are worth rigorously pursuing.

The question is how can you do it with a limited budget? An IRO can help you to perform these duties on a cost effective basis. So if your hospital is looking to improve patient outcomes, quality of care and patient safety, and you understand how the peer review process is hampering the achievement of those objectives, call an independent review organization today and bring them into your quality of care review process. You’ll find an immediate benefit to all parties. Objectivity, clarity, accountability, cost effectiveness and timeliness are just some of the benefits that your hospital can achieve when it uses an IRO for medical peer review.

The Importance of URAC

AllMed Healthcare Management has been a URAC accredited independent review organization for almost five years. We’re very proud to have been one of the original IROs to seek accreditation under URAC. This accreditation now shared by other IROs is a mark of both commitment to quality and continuous improvement.

URAC accredited IROs have gone through the rigorous development and adhere to a core set of standards. They’ve also been through the process of improving their organizations, documenting their processes, procedures and policies and developing quality management and quality improvement projects in order to enhance the overall quality of their independent review process. As an independent review organization with URAC accreditation, we feel that URAC brings us significant credibility benefits. Many states have adopted URAC accreditation as one of the key guidelines for certifying or licensing an independent review organization in their state. Other companies have agreed only to do business with IROs that are URAC accredited. While URAC accreditation alone is not the sole mark of excellence in an IRO, it certainly is the foundation for creating a successful one.

URAC accreditation forces an organization to look at all of its processes and systems from a holistic perspective and to adopt a series of best practices in order to enhance its service delivery to its clients. An organization must not only adopt initial approaches relating to gaining accreditation but also assimilate them into a more permanent set of disciplines that ultimately shape the culture of an organization and lead it to excellence.

Our own experience with URAC accreditation has made our company better in so many ways…let me just list a few.

First, we have a rigorous system for tracking and improving our quality. Our quality management system is a driving force in our company. It helps us to constantly measure and monitor our performance relative to our past, as well as to set new goals and engage in a corporate attitude of continuous improvement.

Secondly, our URAC accreditation has helped us measure and monitor our performance and establish measures for client satisfaction, which we now routinely use to report, diagnose and resolve client problems should they arise.

Third, our URAC accreditation has allowed us to improve the rigorousness of our credentialing and recruiting process for recruiting specialists into our peer specialists panel and has lead us to be able to attract and retain some of the top specialists and sub-specialists in different key disciplines across the country. We also know when to shed physician reviewers who are not capable of meeting our quality and turn around time. URAC accreditation has also helped us to improve the overall planning and execution of our annual fiscal plans, as well as measuring and monitoring our performance against the rules that we set for our company.

So if your company is considering doing business with an IRO for the first time, or getting peer reviews or independent medical reviews done by an outside entity, make sure that you look for an organization that has gone through the rigorousness of a URAC accreditation process. While it’s not the only mark of quality, it certainly is a good way to separate wannabes from companies that truly have committed themselves to continuous improvement and excellence in providing decision making for health care and patient care.

America's Healthcare Crisis

People often ask what is wrong with America’s health care system and what can be done about it? We could spend hours and days on this blog pontificating on this subject. Here are some facts: It’s estimated between 70 and 80% of all healthcare resources in this country are being consumed by as little as 5% of the population, and that the vast majority of that 5% are utilizing resources because of either obesity or smoking.

Smoking and obesity degrades of a person’s immune system and leads to a high cost for the healthcare system…whether it be the cost of treating diabetes, cancer, COPD, heart problems, etc. We need to educate populations about how to engage in more healthy behaviors and live healthy lifestyles. Obesity remains a growing problem in the United States and smoking is still rampant and in some populations, particularly overseas, is growing at an amazing pace.

What are we doing to educate people about the true cost of smoking and obesity? What are we doing to encourage or reinforce better behaviors by incentivizing people to correct these poor actions and to improve their lifestyles? These are questions that we have to ask ourselves as we look at how to increase the effectiveness of the healthcare delivery system, and how to reduce the cost for all. We’re going to have to find a way to reach that small percentage of the population that engages in unhealthy activity, leading to chronic high cost and complex treatments that are draining the health care system overall.