Keys to Understanding Possible Exceptions to MNC

In yesterday’s blog we discussed medical necessity Criteria ( MNC) and stated that we would review MNC exceptions today. 

Learn the keys to understanding exceptions related to Medical Necessity Criteria.  Exceptions covered will include clinical judgment, geographic variance, accessibility of care and determination of what is “essential.” Exceptins to MNC are important to good quality care and quality health care management. Accrediting bodies such as NCQA and URAC address the need to make exceptions when clinically indicated. MNC are subject to different, yet equally defensible interpretations by different clinicians.

 

• Exceptions to standard MNC should be reviewed by a physician or peer reviewer based on accepted standards of good medical practice, and all details of the case should be provided to assist in the decision making. 
• Exceptions may also be based on geographical variances in availability of treatment services.  Cases for this can particularly be found in rural or medically underserved areas. 
• When a medically necessary service is not available the patient will be able to either obtain outside services, or treatment at a higher level of care based on determination of what is “essential” for the optimal care of the patient.

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Clarifying Medical Necessity Criteria

Our group is working with a number of clients currently and a key componenet wrking with both payers of healthcare as well as providers of healthcare is underrstanding and executing medical necesity criteria.  Care managers often struggle over how to intrepret the criteria fairly and povider struggle at how to express the criteria that an idividual patient is exhibiting. Medical Necessity Criteria (MNC), one of the most vital aspects of healthcare and treatment, is still very ambiguous.   Numerous definitions for MNC can be challenging for providers and practitioners to know just exactly how different interpretations can impact care.  Please see the article in its entirety by Robert Levine that  will outline what is essential to understand about Medical Necessity Criteria, and how personal interpretation maintains a role in treatment distinguishing between what is “beneficial” for consumer health and what is “essential.”  Please sign up for our newsletter.

In tomorrow blog I will review MNC exceptions.

Military’s health care costs boomimg.

I am attending and presenting at the Fall Managed Care Forum in Orlando and after a workout began to read the USA today. They reported that Military health care costs rose 167% from 2001 to 2011. The reported increase was due to two causes one the surge in behavioral and physical problems for troops that have been deployed multiple times due to two wars. The other that is most problematic is the rise in retiree costs.  This is reportedly due to retired military leaving civilian insurance programs as the insurance companies and businesses prepare for and  get realigned for the recently passed healthcare reform law.  I suspect we will see more of this as the impact of the law and how businesses adjust and prepare for it. 

US Miliary healthcare spending increased twice as fast as US healthcare spending as a whole.  US healthcare spending increased by 84% over the same time period.  US military spending on healthcare increased from 6% to 9 % of the military’s budget.  They expect this to continue to increase. The Military is considering increasing the cost through fee hikes.

Pay for Prevention: A Strategy for Healthcare Prevention Shows Promise

With all the talk of healthcare or health insurance reform. There are lofty goals and a likelihood that cost will increase.  We will need to think outside the bx to have any real impact on healthcare cost. An idea that focuses on personal responsibility and health as opposed to illness is Pay for Prevention. A few large employers are working on Pay for Prevention. Pay for Prevention is a new strategy aimed at eliminating chronic health conditions associated with bad behavior by offering monetary incentives for leading a healthy lifestyle.  Recent studies have shown that 50 percent to 70 percent of the nation’s health care costs are preventable.  Such costs are usually associated with bad behaviors such as diet, lack of exercise, and smoking.  Healthcare providers, Insurers, and Employers are all jumping on board and the latest indications show that rewards for good behavior are much more effective than punishments for bad behavior.

The unintended consequences of healthcare reform

There has been so much written as well as discussed on the news about healthcare reform.  We at BHM have begun the long process to fully evaluate the 2700 plus page bill and the impact to consumers, payers and providers of healthcare.  The bill has other aspects that are attached that are not directly related to healthcare but that is a discussion for another day and blog.  Most of what I have  read about the bill was politically slanted either for or against depending on the political leaning of the reporting organization. I read, a few days ago, an article from Newsweek which I found interesting and wanted to share. From Newsweek one would expect to be leaning in favor of the new legislation.  The article ” A Cost Control Mirage“ Obama is telling people what they want to hear about health care, not what they need to know by Robert J. Samuelson | Newsweek Web Exclusive.

The jest of the article is that healthcare reform as passed will increase cost with potential little improvement in overall health of the nation. Mr Samuelson begins to discuss the standard payment method used in this country ( fee of service) and how it pays providers for procedures and office visits when patients are sick. This payment structure possibly encourages increased utilization and does not encourage providers to help  patients maintain or improve their health.  He focuses on medical economics and the misperceptions that are held about health insurance reform. Until  we can empower consumers with information and reward healthy choices, we will probably not see change. BHM’s April newsletter that will be addressing Behavioral Economics/Pay for Prevention. This will be released April 6, 2010. You can sign up and the newsletter will be emailed  every other month.

Importance of Financial Analysis

Does your organization use financial benchmarks and evaluations for future planning?  Do you have a clear indication on how your business is performing and where it could improve?  If you answered no to either question then your organization could benefit from a financial analysis.  A financial analysis is a comprehensive tool which is essential to understanding how your business is currently performing, and how you can allocate resources for improvement in the future.  Financial analysis can help you evaluate your return on investment and also give you an edge over the competition in a down market. “Few things are more vital to the success of an organization than a comprehensive financial analysis. It takes the guesswork out of success and can greatly help your organization from a strategic standpoint” said Brian Johnson BHM’s SVP of Fianciacial and Claims Operations.  In fact now when many organizations are experiencing lower profit margins and wide cutbacks a financial analysis can be an important tool in getting the most bang out of your buck.  It can really help you pinpoint your strengths and weaknesses and adjust your planning strategy accordingly.  Analysis can improve profitability, allow you to set benchmarks, assist your organization in optimizing productivity, and allow you to get a thorough look at your finances situation now and into the future.  Tomorrow I will review the essential components of a financial analysis.

Technology Changes Business Travel

I read with interest a recent article about airlines loss of business travelers over the past few years.  Last year business travel was down 60%. They expect business travel to be up this year.  The article went on to say that the industry does not expect to get back any more than half the  business it lost because of technology advances.  We recently assisted a managed care company to become URAC accredited in 3 areas over a  short period of time.  This would have in the past involved lots of travel and on-site meetings.  We did all of it with just one face to face meeting (excluding  a mock survey and the actual URAC survey).   All the rest of the preparation was done via web conferencing.  This reduced the cost by at least half.  Not only was it very cost-effective but the technology lead to superior results, possible because of the way you can focus participants using web-based technology.  If your organization needs high quality cost-effective health care consulting services please contact us for a free consultation.