Payers

Point-of-order clinical decision-support solutions assure that medically appropriate procedures are given the highest priority.

 While research varies, studies report that up to 25 percent of imaging procedures are unnecessary, inappropriate or duplicative. Many health plans have instituted requirements for physicians to provide prior notification or to secure prior authorization. The process is telephone-based and, in many instances, administered by a third-party utilization-management company. In this model, a physician’s office places a call to determine if an advanced study, such as an MRI, CT, PET or nuclear cardiology scan, will be covered for a patient’s specific situation. Most require a preauthorization code in order to be reimbursed.

Integrated provider management is more than simply managing contractual language. A best-practices approach reaches beyond adherence to preferred legal arrangements.

Traditionally, best practices have meant the examination and enforcement of preferred legal arrangements. Health plans, however, have begun to identify the need for a new strategic framework of best practices in provider contracting that reaches beyond adherence to preferred legal arrangements. This is due to the realization that sole focus on the language of a contract and contract obligations limits a plan’s ability to analyze a contract for effectiveness.

New Momentum for HIT

By Vishal Wanchoo, president and CEO, GE Healthcare IT

For nearly two decades, healthcare-industry leaders have promoted a nationwide health-information network (NHIN) to help enable clinical-information sharing across multiple institutions and regions. In 2010, there will be unprecedented momentum at the state level to connect health information across providers.

First, the early adopters of health-information networks are showing how sharing clinical information helps drive better clinical decisions, reduce treatment errors and provide a better patient experience. In addition, the ARRA includes $564 million in funding for states to establish health-information exchanges (HIEs). Finally, the maturing of industry standards and the inclusion of HIEs as a part of the meaningful-use criteria is driving state-level adoption. This framework will play a crucial role in eventually achieving connectivity across states, regions and even nations.

Given the financial pressures that lie ahead for providers as healthcare reform takes shape, analytics become the key to creating new business models that ensure financial viability while improving patient outcomes. Early definitions for meaningful use of healthcare data, for example, include metrics that report on the status quo. Meaningful use can extend well beyond this, by extracting the information that is hidden among the mountains of data collected.

Using predictive modeling and stratification software, Highmark Blue Cross Blue Shield classifies covered members into one of 30 population segments.

Boston-based IDN's database is the foundation of their enterprisewide EMR and CPOE and the cornerstone of their participation in regional and national clinical data exchanges.

In 2004, then Secretary of Health and Human Services Tommy Thompson established the Office of the National Coordinator for Information Technology to coordinate federal IT expenditures, encourage adoption of electronic health records (EHRs), create a national health information network (NHIN), and foster creation of local facilitators of clinical data exchange, regional health information networks (RHIOs).

How one health system competes with a national reference lab for outpatient lab services revenue.

For many hospitals, outpatient laboratory services are a profit center. This is the case for Buffalo, N.Y.-based Catholic Health Systems (CHS), which means that generating incremental growth in volume is a high priority for the organization. Also, like many hospitals, CHS faces strong competition from a national reference lab that has substantial cost advantages, including the efficiencies gained from centralized services at an out-of-state lab; minimal local staffing needs; and, outpatient-only services that eliminate costs associated with round-the-clock staffing, keeping stocks of blood and other critical supplies and maintaining multiple testing facilities

An automated posting and receivables management solution assists an optometric practice reduce A/R and maximize its human resources.

With a new chief executive officer at the helm and opportunities for growth on the horizon, one of North Carolina’s premier optometric practices saw an unprecedented opportunity to improve how it managed receivables and revenues. To that end, Horizon Eye Care focused on streamlining internal workflow to decrease days in accounts receivable and on identifying strategies to maintain current levels of staffing during this period of expansion. Among its top priorities was the adoption of claims management technology that would permit auto-posting to an existing practice management (PM)system with the goal of reducing delays and minimizing reliance on manual processes.