The Right Vision of Health Care?

Yaron Brook, managing director of BH Equity Research and executive director of the Ayn Rand Institute, has a op-ed this week in Forbes by the above title. He brings up several interesting questions and skewers both political parties approaches to health care reform.

But while lambasting the consumer for putting the healthcare burden on government and not paying their fair share, he forgets to mention that healthcare costs have risen to a point where many people cannot afford the healh insurance, let alone the cost of care.

If you're making some decisions about either parties or candidates to vote for, this one is worth a read.

The Right Vision of Health Care

IROs Improve Healthcare

The presidential elections are soon to be upon us, and it's time to start digging deep to find out where each candidate really stands on health care reform. This is no easy task -- most of them hide behind political rhetoric and make it very hard to understand what they will do specifically to address the healthcare crisis, if elected.

No matter what happens in Washington, one thing's certain: Independent Review Organizations will play a critical role in reducing cost and improving the quality of health care as we move forward. We'll explore this topic in detail over the weeks and months to come...

Hospital Peer Review = An Ounce of Prevention....

The old adage about an ounce of prevention is equal to a pound of cure is certainly the case when it comes to sending out suspect issues that have a potential for malpractice or liability litigation in the hospital environment. Why is this? Because while nobody wants to spend their resources defending themselves, the faster you can get to clarity on the root cause of a particular sentinel event in your hospital, the faster you can determine what the appropriate measures to take are in order to protect your hospital from litigation.

Those protective measures could include settling the case early through an offer to a potentially interested party to a lawsuit. It could also include sanctions against physicians or other staff who have behaved improperly, or taking a tougher stance in pre-litigation negotiations when you know that nothing was done wrong and that it can be proven in court that all procedures were followed and the physicians performance which is in question was correct.

Outsourcing cases to an external peer review organization or to an independent review organization can help your company to quickly get to clarity on what the best course of action is as it relates to defending your hospital; sanctioning, taking corrective action inside with your staff, or settling. If you're a risk management professional and you haven't adopted peer review as part of your best practices for your quality management systems, talk to your colleagues, go to industry conferences, and listen to how external peer review is rapidly being adopted or is the best kept secret and best practice of many leading hospitals and hospital groups across the country.

How to Reduce Liability Insurance Exposure

We talk to hundreds of hospitals across the country every week. In our dealings with them we've come to realize that liability insurance carriers who are protecting hospitals are increasingly either requiring or strongly recommending that their risk management professionals insist upon sending all sentinel events out for external peer review. Why? Well, the fact is that hospital peer review is rapidly becoming a best practice for insuring quick case resolution, root cause analysis of sentinel events, and illuminating conflicts of interest when it comes to insuring quality and patient safety.

It's no secret that all insurance companies expend a certain percentage of their revenues on helping their clients to improve their practices in order to reduce costs when it comes to risk management. Professional liability insurers who operate in the hospital group space are using peer review as another strategy to help their clients lower their experience ratio and improve the root cause analysis that leads to a reduction in sentinel events.

The external medical peer review process when integrated into a hospital quality management system provides an outstanding remedy to the professional liability insurance premium escalations that have now turned into a crisis in so many states across America. If you're a CEO or hospital administrator looking for ways to reduce your risk and reduce your liability premiums so that you can reduce the costs of providing services to your patients and your local population, consider an investment in an external review process every time you have a sentinel event that has a potential for litigation. By sending cases out for external peer review, you can often prevent any potential lawsuit by insuring that nothing was done wrong by your medical professionals and hospital staff that lead to a particular sentinel event.

Managing Professional Liability Costs Through Peer Review

If your hospital is like many across the nation, you're facing a crisis in being able to manage your professional liability costs in the face of rising lawsuits and rapidly increasing premiums. What's the root cause of this problem? Well obviously it's lawsuits coming from patients who have experienced sentinel events or negative outcomes such as deaths, hospital readmissions, etc. While these patients and their families are entitled to relief in certain circumstances when medical treatments go bad, the fact is that most hospital administrators are being crushed by the rise in liability costs.

If you are a hospital administrator or CEO and looking for remedies in this regard there are a number of things that you can be doing. First and foremost is taking a holistic look at your quality of care delivery system and in particular, look at your quality management system. Taking an outside assessment of your quality management system can provide insight to where your potential root causes are that are leading to sentinel events and in turn produce the kind of litigation and lawsuits that drive insurance premiums up.

These premiums don't get driven up only by actions in your own hospital but by actions across the board in all hospitals. In our litigious society today it's no secret that when people feel that a service provider (particularly in the medical environment) has wronged them, their first impulse is to find a litigious, fee hungry attorney who is willing to take on a malpractice suit or a suit against the hospital on contingency. Since it doesn't cost them anything to sue, it's very easy for them to get started.

Who bares the brunt on these costs? In general, ultimately consumers do as well as health plans, hospital providers - everybody suffers under an overly litigious system which rewards people for bringing suits against others. If you are a hospital in today's environment there is no question that liability insurance premiums are on the rise and are going to continue to escalate. The exception is those hospitals that can demonstrate the absolute best practices when it comes to quality management.

Importance Of Having A On Site Clinical Staff in Independent Review Organizations

Many independent review organizations actually work without having any onsite clinical staff within their companies. In fact, they have administrative and operational people who provide the coordination of sending, receiving, proofing, and editing reviews that are done only by outside specialists.

Our own viewpoint is that an IRO today needs to have an internal full time clinical staff working inside the company. There are a number of reasons for this. First, having doctors on staff allows us to provide a much higher level of customer service to our clients than IROs who don't. Second of all, those doctors are needed in order to correctly select the right specialists for each review that comes in. Why is this? Many of these review requests are highly technically and only can be decided upon in terms of where to send cases by a physician. Third, having in house physician staff allows us to interpret and communicate with specialists who are on our peer panel at a much higher level than IROs who do not. Finally, many of our clients ask for us to make telephone calls to attending physicians prior to rendering a final review determination. This is next to impossible to organize between a peer specialist who is in active practice and an attending physician. Therefore, it makes sense for us to have our own medical staff that is capable of doing this in house. Typically, multiple attempts have to be made in order to catch an attending physician when they're not seeing patients. Having your own medical staff is the way you achieve this.

For a number of reasons today's IRO is called upon to have a full time clinical staff to be able to interface at the level that is required in order to meet customer demands. Our own clinical staff consists of primary care and emergency physicians. In addition, they are supplemented with physicians assistants and registered nurses who work for them but can still use their medical knowledge to interpret cases and provide some of the background work required as a part of the independent review process.

Independent Medical Review and Customized Reporting

Many of our clients call upon us to provide them with customized reports at the end of each month which outline a number of different elements of the reviews that we've performed for them. From simple reports that list the clients, dates, patient names, and the outcomes through to more advanced reports that relate to reliability, returns on investments, and other elements.

An IRO needs to have advanced database management capabilities which allow them to prepare and customize reports of these natures in order to furnish them to clients on a timely basis. Clients want the IRO to be able to abstract this information and provide it to them for analysis, as opposed to asking the client to take on this burden. As medical management firms, TPAs, and health insurance plans look to outsource more of their medical decision making processes to IROs, it stands to reason that they want to outsource a lot of the analytics and reporting that would go with it. Today's IRO needs to be able to respond with advanced capabilities when it comes to database management, reporting, graphical analysis of data, and interpretation.
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Independent Medical Review and Emerging Standards of Care

It's no secret that we're dealing with an always changing playing field with emerging medical treatments and what is accepted as being a standard of care. Indeed right now we see a shift going on as it relates to the medical necessity of beriatric surgery which, as everyone knows, is a quite complex and very costly treatment procedure for obesity. A few years ago this procedure was being denied systematically by most health plans, and today it's coming into the mainstream of treatment and being more consistently embraced by health plans as a remedial measure for treating patients who have tried but failed at diet and exercise.

An Independent Review Organization needs to stay abreast of these changes as they are happening and adapt its decision making criteria and processes in order to make sure that the decisions rendered on independent medical reviews meet those changing standards of care for medical necessity. Treatments that were once experimental or investigational are moving in the direction of being medically necessary as well. In areas such as cancer treatments we see a number of new types of medicines coming out and being moved through the FDA approval process and then into the mainstream of cancer treatments. An IRO needs to have specialist as well as tracking systems, databases, and information libraries which allow it to continuously evolve its decision making criteria to what is medically necessary in accordance with movements in modern medical thinking.

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Independent Review Organizations and IT Systems

Gone are the days when you can just have Microsoft Word and a couple of other applications at your company and be capable of dealing with the administrative and quality workflow that is required in order to be an IRO. Today, best in class IROs are investing in integrated web applications that provide an automated workflow between clients, their own operations, and peer specialists. In fact, AllMed Healthcare Management is in the process of rolling out it's own application called PeerPoint, which will greatly streamline and improve our ability to automate the workflow.

Companies that want to be in the business of providing independent medical reviews have to have a high degree of integration of their IT systems in order to be competitive. That includes having standardized operating systems at the network level and at the application level building customizing software applications that integrate and provide for administrative efficiency when it comes to taking in, assigning, processing, and returning independent medical reviews to its clients.

An IRO needs to have a quality IT process, standardization of operating systems, privacy and security procedures as it relates to IT information systems. These are all the kinds of things that the IRO has to maintain from an IT standpoint in today's environment.
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Independent Review and State Regulations.

Independent review organizations are primarily regulated at the state level. The myriad of regulations makes it a very complex task for an IRO to track. State regulations in turn can be quite difficult to interpret and require an advanced understanding and ability to interpret legal jargon and long, complicated, government documents. The IRO must have an ability to manage, maintain, and anticipate any changes going on at the state level that could change the way in which it must operate. Our view is that these state regulations are very encumbering and we would like to push for a unification of healthcare regulations at the national level that would greatly ease the administrative burden on organizations that are doing business across multiple states. In particular, an IRO like ours which is doing business in more than 30 states needs to maintain a heavy administrative overhead just to track and manage the changes that relate to state regulatory bodies.

We believe that this kind of tracking and management is really wasteful and if a set of national standards would emerge it would make it much easier for us to adhere to one set of standards as opposed to having to manage multiple ones. In any case, the modern IRO must be capable to adhering to all of these standards. It's part of the reason why being an IRO is not a trivial task.

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IROs and Customer Satisfaction

One of the key elements of our business is making sure that we consistently exceed our customer's expectations for quality, turnaround time, customer service, and the other measurements that we have established for our business. Indeed our recent customer satisfaction survey came back indicating that we had better than 85% of our clients that rated us excellent or above average in all major categories. Despite this, it's still not good enough for us.

Our goal is to consistently improve our customer satisfaction. It is that culture of continuous improvement that an IRO needs to have in order to correctly adapt to the demands of today's marketplace. Customer satisfaction translates into many operational initiatives in quality, response time, investment and phone systems, tracking procedures, etc. in order to identify, escalate, and quickly resolve issues so that our clients are completely satisfied.

An IRO needs to be highly responsive to it's customers. One of the distinguishing features of the best IROs is that they have doctors that are available to provide free consultations to their clients over the telephone as a part of their client relationship. Some IROs don't even have in house doctors and rely only on contracted specialists to provide the independent reviews. We found in our business that our clients appreciate us because of our ability to put our own medical staff on the phone with them quickly and consistently to answer their questions while providing that level of expertise and interface, even if we're just translating information from our other specialists on reviews.

An IRO needs to have a commitment to continuous improvement and customer satisfaction. That translates into a variety of investments that need to be made in order to meet the needs of today's health insurance payer.

IROs and Employee Training

Today's IRO needs to continuously invest in training its employees whether it be on clinical procedures, quality metrics, industry trends, administrative procedures, or customer satisfaction improvements. These are the types of training topics that come up regularly inside the organization. In addition to that you have of course ongoing training on privacy, confidentiality, and security issues which are absolutely critical to an IRO's credibility with its clients as well as its own ability to meet federal and state laws.

Regulatory requirements are another area in which an IRO needs to regularly train it's employees in order to keep them abreast of the state regulations that govern independent review. Especially a national IRO like ours, which is doing business in more than 30 states, needs to be attune to this and regularly train and track these requirements with our employees. An IRO, by necessity, is a training organization continuously investing in keeping its people up to date on the latest systems and procedures related to independent review.


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The IRO and Quality Management

IROs are expected to have advanced quality management system much like you'd find in any other organization, which is responsible for delivering a consistent level of high quality to its customers. If you've been in the manufacturing world you've heard of Total Quality Management. The kinds of principles that we've heard and read about for many years in other circles are certainly applying in today's healthcare system. Rendering a consistent evidence based decision is absolutely critical for an IRO as it relates to making sure that it's upholding its two most important goals: maintaining the highest level of quality and patient safety.

Our quality management systems include a number of different types of URAC oriented initiatives. First of all, we track all of our quality data and review it on a regular basis. Second, we have a number of specific measurements and metrics that we use in order to measure how well we're doing as an organization. We track everything from error rate to customer complaints to interior reliability. These are just some of the measurements which are used to ensure make sure that we are consistently delivering quality to our payer and medical management clients.

Quality management systems inside an IRO looks, acts, and behaves very much like a quality management operation in any modern company with an emphasis towards quality assurance. Quality assurance of course relates to taking preventative measures through training, systems development, incentives to employees, and other techniques to make sure that a consistent quality product is always delivered.

Quality control, on the other hand, means checking and catching any errors after they've happened. A good IRO is going to focus on insuring quality by building those upstream systems and processes so that they can prevent those errors from happening in the first place.

Today's IRO has a high degree of accountability to it's clients for quality management and some of the systems and processes that I've mentioned here certainly are things that you should look for if you're thinking about selecting an IRO.

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Independent Review and Turnaround Time

We have a variety of clients across the country who are bogged down with their own administrative procedures and often times by the time they request an independent medical review from us, we only have one or two days in order to perform these reviews. Because of this, we developed our organization to be able to respond very quickly on the to incoming requests. We've lined up a panel of specialists who are well trained and understand that their value to our organization depends upon their ability to drop other things on their day schedule in order to complete reviews for us so that we can get them back on a same day basis or rush basis to our clients.

We have lots of clients that have come to us because our goal is to consistently exceed the URAC specified turnaround times for medical reviews. Right now our organization is averaging one. One day turnaround times for expedited reviews and we consistently average 3 days for standard review even though the standard for that is 3-7 business days. Companies that are looking for fast turnaround times on their independent medical reviews demand that an IRO is capable of meeting those needs. The modern IRO today needs to be capable of providing a service that meets or exceeds those URAC standards.



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Independent Review and Mass Customization

When you have hundreds of reviews being done each day and dozens and dozens of clients who are each asking for the reviews to be prepared just slightly differently from each other you can imagine how intricate it is to manage all of those different reviews and customize them according to each client's exact needs. We call this mass customization, which is certainly what is referred to in manufacturing when companies are mass-producing lots of different variants of the same product. Dell computers is probably the best example of a mass customization company who has really mastered this concept. Similarly, IROs also have an incredible ability to mass customize their product and service. The reason this gets done is because each new client has it's own set of parameters that are recorded into the IRO's operating procedures. An IRO needs to be able to mass customize in order to meet the demanding requirements of each of it's different clients.

Why do those requirements vary so much from company to company? Well, IROs are used differently by just about every single type of business. Some companies do first level reviews. Other companies are doing second and third level appeals. Some clients are using us for preauthorizations of medical treatments. Yet again, another group of clients could be looking at us to do quality management reviews. Each of those clients has a different set of needs and the independent medical reviews that we provide for them are integrated into their operations at a different stage of the process. This is why it is so important that an IRO can customize each review to each client’s requirements in addition to meeting demanding turn around times.

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Independent Review as a Highly Optimized Work Flow

We hear about companies that are considering getting into the business of doing independent medical reviews and indeed, on the surface it looks like it's quite easy for any doctor to organize a small panel and start doing specialist reviews for a few clients. The fact is, that in today's environment, an IRO is called to build rigorous processes and standards and the investment required in order to do this correctly to meet the demands of large health plans and other healthcare organizations is very rigorous. I would like to outline in the next several blogs why it is that independent review is not a trivial, easy to organize function inside any organization, and why it requires a significant amount of investment and diligence.

The first thing to know about any IRO is that in order to be competitive they need to have a highly optimized work flow that breaks down the independent review process into a number of standard steps capable of providing a consistent level of turn around time and quality. Today's independent review organization typically has a staff of operations people, clinicians, as well as several software applications, each which have been brought together to organize a workflow that is capable of meeting the turnaround time of our customers.

When 20, 30, or 50 of our clients are calling in review requests that need to be received, dispatched, typed, proofed, edited, and finalized within a 24 hour period, you can imagine how demanding that is on your systems and procedures and how critical it is that your organization has optimized all aspects of the process. We have invested considerable sums of money into integrating our applications, databases, reporting, tracking, data entry procedures, word processing systems, and other aspects of our business including accounting, sales, and customer service in order to be able to provide the level of responsiveness the average health insurance payer or manage care organization needs. The independent review process itself requires an incredible amount of efficient organizational streamlining in order to be effectively and competitive.

The Pressure Cooker of Healthcare Claims Management

We talk to claims adjusters, supervisors, and managers all over the country and the common theme that we hear from them is how increasingly demanding their jobs are and how difficult it is for them to keep up with the workloads that they're facing. In particular, many payer organizations are fighting to reduce costs and look for greater efficiencies.

In the advent of downsizing and layoffs, a lot of claims organizations employees are forced to work twice as hard as they used to in the past. Does this sound like the situation at your organization? If so, one thing you might want to consider doing is employing the services of an IRO where you can outsource your most difficult and complex case decisions.

The reason why you'd want to do this, is because it will make your day go better! If you are a claims adjuster who simply cannot keep up with the level of work that you have on your plate, using an IRO is a way to extend your resources and get more done while making sure that the job gets done right consistently. This is why increasingly Third Party Administrators and health plans are outsourcing their case management to companies that are independent review organizations. You should consider doing the same.

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Consumerism and the Independent Review Process

At the recent URAC Quality Summit in San Diego, we attended several sessions that focused on consumer directed health plans and the advent of consumerism in healthcare was the dominant topic at the conference. As many of you know, URAC is an accreditation body that governs IROs as well as utilization review, medical management, health plans, and other types of organizations in the healthcare sector.

The topic of consumerism is a hot one right now. It really relates back to the whole issue of how consumers are being driven to take a higher degree of responsibility and become more involved in directing their own healthcare decision-making. Why is this? With the advent of high double-digit increases in health care premiums, cost shifting has forced consumers to become more involved in figuring out how it is that they're going to spend their healthcare dollars. Certainly, the advent of health savings accounts and other types of tax advantage plans has also had a major impact on this.

Many people ask us how independent review plays into the consumer driven health plan momentum that is gaining in the United States right now. The fact is that IROs, when providing independent medical reviews and pre-authorizations, are not dealing directly with consumers (or at least very seldomly). However, IROs are the behind the scenes mechanism helping to insure that patients get what they are supposed to get consistently according to plan language, standard of care, and necessity.

Consumerism does not effect the independent review process directly, other than the fact that as consumers become more involved in determining how and where they're going to get their healthcare treatment, there is certainly going to be more conflicts and questions that come up with regard to how those dollars get allocated in the system. This is where an IRO plays a pivotal behind the scenes role in this process. Consumers won’t come to IROs in order to get a claims pre-authorized or adjudicated, but individuals will indeed benefit from the IRO process as it relates to ensuring that patients get what they're supposed to and that subscribers receive the healthcare that they deserve according to the plan language that they subscribe to.

As consumer directed health plans continue to increase, and the independent review process becomes a bigger part of the mainstream of best practices for allocating healthcare resources, we expect the two to converge more and more even if IROs don't deal directly with the public.

Improve Hospital Quality Management - Outsource Peer Review.

If you're a quality or risk management professional inside a hospital you know how challenging it is to keep up with all of the tasks required to manage a quality operation. That's why risk managers today are increasingly looking to outsource non-critical functions to service providers in order to improve quality while maintaining or surpassing standards.

Outsourcing hospital peer review to an IRO is a perfect example of a best practice that is rapidly being adopted by many hospital risk and quality managers. If your hospital is experiencing sluggishness and difficulties in getting its most challenging peer reviews of sentinel events completed in a timely fashion, an IRO can quickly come in and shift that paradigm for you.

We work with many hospitals across the country that have had sticky sentinel events and cases that have been languishing for 6-9 months with no case resolution because they lack available specialist reviewers or a there is some sort of conflict of interest situation. These cases can easily be solved by bringing in an IRO. The IRO can quickly take over those cases, send them out to board certified specialists in active practice in the same specialty area as the cases to be reviewed, process those responses back into a comprehensive report for a single file or multiple charts and return them to the hospital quality management team, typically in less than 30 days. This provides and incredible amount of value to hospitals that are under the gun to meet their requirements yet are struggling with this process.

If your hospital is looking to outsource peer review, my suggestion is think about moving forward with this right away because frankly, hospitals that don't are falling behind in what is becoming a standard accepted practice in the industry.

Making the Right Utilization Review Decisions

As a case manager working in utilization review, you don't want to be denying patients treatments that they deserve. At the same time, you don't want to be preauthorizing expensive and complex procedures that are not within your patients plan language or medical necessity. This is why using an IRO is so important.

It's impossible to know what decision is right in every single case based upon the medical evidence inside the chart. Utilization review professionals simply don't have the time to get all of the facts and work through every aspect of the case before a decision needs to be made and a preauthorization of treatment is allowed. That is why an IRO can greatly expedite the decision making process while ensuring that the decision is made upon the medical evidence and the facts.

If you are a case manager or utilization review nurse and you're not using an IRO to back up your medical decision making, you're not following best practices in today's market place and you could be putting you and your company at risk of making decisions which will end up getting your company into trouble. If you are interested in knowing more about IROs go to the National Association of Independent Review Organization’s website for more information.

Utilization Review Made Easy (Part 2)

If you are a case manager or utilization review nurse, I can really empathize with how much pressure you face in your job to make fast decisions on a myriad of different medical issues and types of cases, without a lot of time for deliberation. Yet, in today's day and age it is even more important for you to be able to make effective decisions and know that you're using the latest knowledge and the latest standards of care in order to back up your determinations. If you are a managed care nurse or a utilization review specialist you can't afford to do this without the backing of a good IRO.

Why is this? The standard of care is too complex. The answers to medical necessity questions are constantly shifting. New technologies are coming online. New treatments are going from experimental/ investigational to standard. As a utilization review nurse you can't possibly be expected to be able to stay on top of all of these changes and shifting standards. Using an IRO and plugging into the specialist knowledge base is absolutely critical to the utilization review function today. That is why most Utilization Review companies and medical management firms have made this a best practice.

Utilization Review Made Easy

Are you a utilization reviewer or case manager who struggles with the moral dilemma of denying patients the care that you believe they should have, even though it's not covered under their plan language? We talk to many managed care nurses who face this dilemma. In fact, some of those people that we talk to have actually left those positions because they're tired of forcing patients to get care which is not substantial enough in order to treat them properly.

If you're a utilization review nurse and having a hard time with this, one way that you can greatly enhance your ability to deliver the right health care and make sure that nobody gets denied treatments that they deserve is by employing the services of an independent review organization (IRO). Why is this? IROs work to ensure that patients get the coverage that they deserve under to the plan language and according to the standard of care and make sure that the patients medical necessity is always put at the highest level of priority when it comes to making those care decisions. IROs employ doctors and physician peer specialists capable of reviewing the details of a patients chart notes and making the right decisions.

Typically, an IRO's default decision when ruling on care decisions is "Yes." Why is this? Because most managed care organizations do want to do the right thing for their patients and their subscribers. Managed care organizations and utilization review companies actually pay IROs to make sure that there is no systematic denial or bias against patients as they make those decisions on health care utilization.

If you're a utilization review nurse or case manager looking to make sure that your patients get what they deserve, consider outsourcing the most complex and difficult cases systematically to an IRO. What you'll find is the consistent application of evidence based decision making at the highest levels, deploying specialists who treat patients in the same area as each case involved. This will allow you to avoid any misgivings about whether or not effective decisions are being made and patients are getting what they deserve.

Continuous Improvement in Hospital Quality of Care

Hospitals like any other business are under continuous pressure to improve their quality of care, and focus on improving outcomes and overall patient safety. Most hospital organizations today have adopted quality management best practices to ensure that services for their patients are uniform, consistent and meet the highest quality standards possible.

We work with many of the largest hospital chains across the country and see their dedication and commitment to continuously improve quality. Patients of the heath care system should be pleased to know that most hospitals are in fact working very hard to evolve and improve their quality standards.

There are however exceptions. Some hospitals have nagging problems related to specific sentinel events and negative outcomes. Often what we find is that there's a correlation between high incidence of bad outcomes and a poor quality management process. Sometimes times the missing ingredient in a quality management system is leadership. When a hospital or medical provider is consistently suffering from a high number of sentinel events, typically it is because there is a lack of quality management accountability inside their system and a lack of follow-through on corrective or disciplinary action which is necessary in order to ensure the highest standards.

How can this be resolved? The starting point is for the leaders in these problem hospitals that are suffering from this problem to take notice and engage the necessary resources in order to create real, lasting change. The leaders can set up and commit to making changes and go through a change management process.

Certainly an Independent Review Organization can be brought in to help overcome any conflict of interest or other issues related to protection of certain physicians who are misbehaving or underperforming. The role of an Independent Review Organization in exposing misdiagnosis, mistreatments or a physician’s underperformance can be a very important one. The reason is because an Independent Review Organization can provide an objective, unbiased, decision making that helps hospitals clearly understand when they have underperforming physicians instead of making these decisions based hearsay, personal grudges, insinuations or guess work.

The Independent Review Organization plays a vital role in taking the guesswork out of making sure that physicians are held accountable and exonerated when they have done nothing wrong.

Helping Third-Party Administrators Manage Healthcare Claims Costs

Independent Review Organizations work with Third Party Administrators across the nation to deliver better care decisions and allocate healthcare resources more effectively.

Why is an Independent Review Organization so important to this process of working with Third Party Administrators? It's simple. First of all, third-party administrators are called upon to ensure that effective claims decisions are made for each patient and that benefits are allocated according to plan language, medical necessity as well as standard of care. Yet third-party administrators typically do not have the in-house medical staff to perform this function. So they need to rely upon the services of an outsourced medical review company, or Independent Review Organization, to make these determinations effectively. As a result, third-party administrators depend heavily on Independent Review Organizations for allocating medical and healthcare resources regarding the most expensive and most complex medical treatments.

Usually should a Third Party Administrator have a medical director on staff, typically they are generalists and cannot be expected to have medical knowledge across a whole spectrum of different types of healthcare treatments and medical specialties. This is where employing the services of an Independent Review Organization can make a huge difference in terms of improving an organizations ability to make those decisions. This is also why third-party administrators today rely heavily on Independent Review Organizations to get their medical reviews done fast and efficiently.

Evidence-Based Medical Review Determinations

There is much debate about the role of evidence-based medicine in making effective healthcare decisions. We’re strong supporters of using medical evidence to determine whether or not a patient should receive a suggested treatment.

However, the debate about evidence-based medicine sometimes goes beyond the practical. One cannot generally apply evidence based medical principals to every case without understanding the specific context of an individual patient diagnosis and treatment. This is where using a panel of board certified specialists who actively perform the procedures that they're reviewing and pairing up those specialists with specific case circumstances is the most effective way to make a decision. It makes sure that not only is the medical evidence taken into consideration when making a patient case, but also that the situation of the patient based on the information in their medical chart.

We believe that evidence based medicine needs to be balanced against the knowledge and experience of doctors who are performing certain treatments and their practical experience in determining what the best treatments are and what the standard of care is.

Optimizing Your Request for Medical or Peer Reviews

If you're a claims manager, utilization management nurse or case manager and you're sending cases to an Independent Review Organization for medical peer review, here are some important tips that can make your next review easier and maybe cost less.

1. Your request should clearly state exactly the issues that you want us to review about your case. Point out the defining issues which are most important to consider.

2. Ask clear questions that get to the heart of the matter or the issue that you're trying to get a determination about. From time to time, clients send us vague questions or ask redundant or extraneous questions that don't get to the heart of the matter. Framing your questions properly is very important when you're requesting an independent medical review.

3. Don’t overstate the number of questions you want answered, because the cost of an independent medical review is directly a function of the number of questions that you want us to review. The cost of course is also driven by the number of pages that we're requested to review. When we look at thousand pages on a case, obviously it's going to cost a lot more than hundred pages.

4. Another way that you can reduce the cost of your medical reviews is to make sure that you only send us the pages that are really relevant to your questions. Of course we don’t want our clients to skim through and eliminate pages that could provide good background information on the case. On the other hand, it does make sense to eliminate any extraneous internal communications that are not germane to the case before they're prepared and sent to us.

If you are considering sending cases into an Independent Review Organization for medical review, make sure that you frame your questions properly and succinctly and that you reduce the questions to the ones that are most important to rendering a determination.

Our Nation’s Healthcare Costs are Spiraling Out of Control

Almost every day we read in the newspapers how healthcare costs continue to rise at a double digit pace. As employers each year we are chagrined to hear from our health insurance carriers that they're passing on 12 to 15 to 17 percent increases in health care premiums. We respond by shifting costs over to our employees by increasing the deductibles and co-pays hoping to stem the tide of uncontrollable healthcare costs. Yet, they continue to rise.

We want to do something about this. Clearly one of the things that we can be done is to make sure that in the healthcare system today, the resources are allocated only to those people who deserve and qualify for the treatment that they're seeking on the basis of medical fact. AHIP commonly estimates that 30% of all healthcare treatments are unnecessary. We believe this to be the case because it mirrors our own statistical denials of healthcare benefits on the cases that we review for major health insurance carriers, Third Party Administrators and other clients.

The point is allocating health care resources an important part of medical cost containment equation and something that we should all be concerned about? Certainly our company is not at the forefront of this. Our role is to simply provide independent medical review services that help payers allocate their resources more effectively. We believe there are many other ways o to solve this problem, and Independent Review Organizations are adding increasing value by helping to contain medical costs.

As a member of the National Association of Independent Review Organizations (NAiro), we’ve banded together to press for changes in legislative and regulatory areas at the state level and to seek to unify the bureaucratic regulations that are tangling up our healthcare system at the state level and leading to increasing costs. We also are pushing for better ways to improve the overall healthcare system by advocating standards for credentialing Independent Review Organizations.

All of the NAiro members are accredited by URAC which has helped us to improve our overall quality and to insure our clients that we meet high standards of performance when it comes to medical review quality, turn around time, objectivity and evidence based decision-making. NAiro is pursuing an aggressive agenda among its members to improve the overall responsiveness of the industry to changing healthcare trends, as it relates to emerging treatments. We're also working actively as members of the URAC board to push forward an agenda that will make it easier for healthcare organizations to select credentialed organizations as their healthcare vendors.

What other ideas do you have that could be implemented on this subject for our national advantage. We'd love to hear you at info@allmedmd.com.

Online Service versus Faxing

Why does it make sense for us to push patient health information through a secure Web application as opposed to sending or faxing charts? Obviously there are cost reduction reasons for this. And with the advent of new electronic health records, more and more information is being stored digitally by healthcare organizations. There's a great opportunity to take advantage of this in order to store and move electronic health records and medical review cases through the system in a digital format.

We believe that our PeerPoint software will enhance this process and that Allmed will emerge as the leader in independent review software for Independent Review Organizations. Why is this? We've been spending the last year working on a customized and highly optimized, Web-based work flow application that mimics the way we work today. Effectively our PeerPoint software will collapse the myriad of client server software programs that we currently use in our office into a single fully integrated solution for your independent medical reviews.

We expect to launch this application in the next couple of months and are confident that our clients will see immediate benefits like being able to swiftly and securely transact business with us.

Healthcare Workflow Software Makes Great Sense

If you are a hospital or health insurance payer today, there are a myriad of workflow applications available to help improve efficiency and reduce cost in your organization. Everything from inscription software, to case management systems to finance and accounting software has been specialized for clinical practices. Those are just some of the examples of the way organizations can use software to perfect their business processes, reduce their costs and improve the overall viability of their organizations and its competitiveness.

A good example of workflow software in the healthcare arena is the use of Web applications for conducting reviews. Whether it is a independent medical review for health plans or hospital peer review, today there are new cutting-edge applications that support the Independent Review Organization review process and allow for the exchange of critical, confidential patient information (PHI) in a secure, Web based work flow.

We're developing a Web-based application at Allmed called PeerPoint. This software will allow us to transact with our business partners, clients and specialist doctors across the country securely and greatly enhance our ability to efficiently track and manage cases as they move through the medical review process. We're excited about this software and the benefits that it's going to offer to you, our clients. You will have the ability to check the status of cases online. We will benefit from internal cost reduction and improve the scalability of our company.

If your company is considering deploying Web applications in a healthcare environment, in particular if you're thinking about deploying a custom Web application, we can give you some advice and ideas, because we've spent the last year developing experience and perspective by building ours.

Taking Corrective Action After Peer Review

We perform quality management reviews for many of the top hospitals across the United States. When we talk to risk managers and quality managers involved in these cases, one of the questions we commonly ask is, "How do you use the determinations that we provide to you? When we perform a hospital peer review, what do you do with the information? How do you integrate that information into a corrective action plan?"

The fact is we get various answers from different people on this subject. If necessary, some quality managers use our hospital peer reviews for disciplinary action with physicians who have engaged in things like misdiagnosis, mistreatment or outright provider fraud.

Other hospitals haven’t integrated their peer review and their corrective action process to close the loop on these subjects. Hospitals that have a disconnection between their peer review function and taking effective corrective action are missing a great opportunity to improve quality. In fact, one of the things we ask ourselves is: "Why would they have us conduct a peer review if they don't plan to do anything with the information?"

Because large organizations take on their own culture and politics, we believe that’s one of the reasons why peer reviews aren’t sometimes converted into corrective action. If large hospital organizations scrutinized the work of one of their top physicians, it’s very easy for them to avoid conflict arising from a discovery of wrong doing by that physician. Many times it's easier to suppress these conflicts than it is to deal with them in a healthy, open and fair way. This is one of the dilemmas for any large organization when it comes to self-policing and pressing for continuous improvement. Certainly, it is one of the key issues that hospital organizations face with respect to improving quality management today.

Cost Pressures on Healthcare

Like everyone else today, cases managers and health care professionals are being pressured to reduce costs and eliminate treatments wherever possible in order to control the double-digit increases in healthcare costs across the nation.

How can you as a case management or utilization review professional be sure that you’re reducing cost while still effectively ensuring that patients and members of your health plan consistently get what they're supposed to?. One of the most common solutions for this today is to bring in external medical review resources to look at cases that are either very complex or that require a specialist’s review before making a final decision.

Do you have specialists available to your organization to perform these reviews? If you do, you're among the few because most organizations today can't afford to employ or retain advanced physician specialists. For those case managers and utilization review nurses who don't have those kinds of specialist resources at their disposal, the best answer is to outsource those cases to an Independent Review Organization.

External Quality of Care Reviews for Provider Organizations

If your hospital or a medical group has doctors seeing patients on a regular basis, you need to perform quality management functions to determined and verify the proper quality of care. Traditionally organizations do this internally using their own nursing resources and physician peer panels.

Increasingly, companies are outsourcing this type of activity to an Independent Review Organization which can assign a specialist to look at specific cases and determine root cause analysis of any care deficiencies. This makes sense when the hospital or medical group has a shortage of specialist availability to look at cases that are complex and require a specific specialist to review a sentinel event. Outsourcing this function is becoming more common among leading medical organizations and hospitals.

We're working with the top three hospital chains in the country and they are increasingly viewing peer review as a non-core activity that can be cost effectively and easily outsourced. They understand that this makes sense, because they can get it done faster using and Independent Review Organization then they can internally. They also understand that when sentinel events occur, and their organization risks expensive lawsuits or sanctions, the cost of actually performing these external hospital peer reviews is miniscule in comparison. That’s why providers are looking more and more to outsource quality of care reviews to Independent Review Organizations like Allmed.

Managed-Care Nursing Made Easy

If as a utilization review or utilization management nurse or a case manager, your job is to pre-authorize complex claims and treatments, one thing that you can do to make your job easier is to outsource your most difficult cases to an Independent Review Organization. We work with hundreds of organizations across the United States that do this. They have found great benefit in terms of cost reduction, and speedier decision making when it comes to preauthorizing expensive or complex treatments. Managed care nurses typically have many years of health care experience. Often they have many years in clinical practice that’s also supplemented by years of case management reviewing many different types of cases and treatments.

Despite these years of experience, case management nurses and Utilization Review nurses cannot be expected be up to date on all the newest medical treatments and diagnoses. In fact, the standard of care continues to change. What was once viewed as a cosmetic treatment can now be diagnosed as medically necessary because those standards change.

This is why an Independent Review Organization is so important to a managed care nurse. What it allows you to do is extend your reach by allowing you to tap into the up to date knowledge of top specialist physicians across the country to make preauthorization decisions more effective. It’s widely considered a best practice today.

Some manage care organizations and medical management firms have their own panel of physicians, yet increasingly the best Managed Care Organizations and Utilization Review companies are outsourcing this function. Why? They can't compete with the services of an Independent Review Organization for cost, credentialing, availability or turn around.

Claims Management Made Easy

If you're a claims manager or adjuster workers comp, auto, health or disability insurance, one of the scarcest resources you have is your time. When you have complex and costly cases, your time gets eaten up adjudicating claims and consulting others for opinions. If you find yourself in positions where you're stretched too thin, a great way to extend your capabilities and to move your most difficult cases through your organization is to use the services of an Independent Review Organization. Independent Review Organizations are dedicated to providing medical decision support to claims payers of all types on healthcare benefits or on medical benefits related to specific treatments. An Independent Review Organization provides an external, objective medical review service for insurance carriers, Third Party Administrators, and other types of payers. Independent Review Organizations help them allocate their resources effectively and provide decisions about the approval and denial of treatments.

Independent Review Organizations are typically accredited by a URAC (at least the good ones are). They provide a panel of external peer physicians in all specialties and sub-specialties who are capable of providing standard or expedited reviews of health care cases by determining their medical necessity, standard of care, whether they are experimental or investigational, whether they indicate an appropriate length of stay in hospitals and other types of questions that a doctor must review.

The Independent Review Organization always matches the case with a specialist having the same background as the referring specialist. Independent Review Organization specialists are always board certified, licensed and in active practice. This insures is that you will be able to use the same expert knowledge to make your claims decision as was originally applied to the treatment being considered. It allows you to speed up your claims decision making, eliminate unnecessary medical treatment, reduce premium costs for disability and workers comp and ensure that your claims resources are being allocated to members who deserve the care, and not those who don’t.

So if you're a claims manager and you're not using an Independent Review Organization today to evaluate claims inside your organization, consider one.

Improve Your Appeals Decision-Making Process

Many health care organizations have appeals units that are set up to review appeals for benefits denied their health plan members. Often they struggle under the heavy workload related to responding according to state-mandated deadlines for these appeals. Many of these organizations have built up large case management and medical claims departments in order to meet those requirements. They are trying to respond to their case load, but in fact, these health plans are really in another business—and it’s not case review.

When health plans want to improve the quality and speed of their appeals decision-making, they should consider outsourcing these decisions to an Independent Review Organization. Because an Independent Review Organization is much effectively set up to handle large volumes of appeals in a way that is more expeditious and lower cost than a health plan can do so internally. The issue isn’t whether or not Independent Review Organizations have lower cost physicians. They don’t. In fact, we employ many of the top physicians and specialists in the country. The point instead is health plan providers can outsource medical decision making highly qualified physicians on a pay as you go basis—and only pay for a fraction of the doctor’s time at a reasonable hourly rate.

Independent Review Organizations assist a large number of the biggest health insurance carriers today with their appeals decision-making support. Is it time that your organization consider outsourcing this? If you're keeping this kind of work in house and are staffing your organization with a group of doctors to review these appeals, you might want to consider whether it makes better sense for you to send these cases to an Independent Review Organization for external review.

An Independent Review Organization can help you to match each case with a board certified, actively practicing specialist or sub-specialist for every case that comes through your appeals process. This is something that’s very difficult for organizations to handle internally. Even if your organization has a provider arm locating, tracking down, and retaining the services of a specialist to review a case, often times it's very cumbersome them. And it’s not really the business they are in. Instead sending these cases out to an Independent Review Organization that has a pre-selected specialist and sub-specialist panel makes more sense. And it can be done at lower cost and with much speedier turn around times.

Turn around time is a key concern for complying with state insurance regulations, which typically call for an expeditious appeal process. If your organization hasn't begun outsourcing to an Independent Review Organization yet, you should consider investigating the benefits of doing so. You'll find that you'll reduce your cost and you'll improve your regulatory compliances as a result.