Payers

The universe of provider information is rapidly expanding and changing across the healthcare ecosystem.

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.