Good article on hospital utilization management and reducing re-admissions, denials, and better overall care
Please also review our Healthcare Case Management Program
The article, Hospital Utilization Management Can Reduce Denials, Improve Care, states,
“Utilization management in healthcare is commonly thought of as a strategy that payers employ to control resource use within physician offices and hospitals to keep healthcare costs down. However, hospital utilization management programs are also an essential part of a provider organization’s revenue cycle, helping to prevent unnecessary costs and claim denials.
According to the Healthcare Financial Management Association (HFMA), healthcare utilization management is the “integration of utilization review, risk management, and quality assurance into management in order to ensure the judicious use of the facility’s resources and high-quality care.”
Comprehensive hospital utilization review and management are key to preventing denials and lodging successful requests for appeals.
Medicare and Medicaid use Recovery Audit Contractors (RACs) to review claims and detect improper reimbursement for incorrectly coded services, non-covered services, and duplicate services.
RACs can deny claims and recover improper reimbursement by reviewing medical records to determine if healthcare utilization was appropriate.
The average number of medical record requests and denials from Medicare RACs is on the rise, the American Hospital Association (AHA) reported.
Hospitals reported receiving an average of 1504 medical records requests by the end of 2016, up from 1424 in the first quarter of 2014.
Utilization management and review can prevent hospitals from receiving retrospective claim denials and being forced to relinquish money already received.
Hospital utilization management programs will also become increasingly important as organizations take on value-based reimbursement models. Prior authorizations and medical record reviews are key for providers who are at risk for over- or underutilization.”
To read the entire article, please click here
Please also review our Healthcare Case Management Program and see if it matches your academic and professional needs.