Each week, we add informative, thought-provoking blogs and news updates pertaining to healthcare operations, written by symplr and industry experts.
These were the most popular blogs of the past year.
1. Most Important Metrics for a Healthcare Quality Management Dashboard
By Joni Orand, Senior Solutions Consultant, symplr
When it comes to healthcare, we all want quality over quantity. Put simply, no one wants to spend more time at the doctor’s office or in inpatient care. Value-based healthcare models aim to deliver on this goal by moving us beyond fee-for-services models—which by default encourage more tests, more procedures, and more follow up.
Instead, payers will reimburse providers not for quantity of care, but for clinical outcomes tied to cost containment. To succeed in the transition, healthcare organizations must implement strategies that effectively track quality metrics and improve care with the ability to demonstrate evidenced based outcomes.
2. How to Avoid Stark Law and Anti-Kickback Statute Penalties
By Maureen Clarke, Editorial Director, symplr
The stories behind headlines like these can have a chilling effect on healthcare administrators and compliance professionals:
- Texas Heart Hospital to pay $48 million in alleged kickback settlement
- Oklahoma hospital to pay $72 million settlement over alleged kickback scheme
While the news focused on the hefty monetary fines, Stark law and Anti-Kickback Statute violations can also lead to exclusion from federal healthcare programs, prison time, and reputational damage. Healthcare fraud and abuse laws and regulations are designed to protect patients and prevent waste, fraud, and abuse in federal healthcare programs.
3. 6 Tips to Navigate Insurance Peer-to-Peer Reviews
By Patrick Birmingham, Executive Vice President of Credentialing Operations
Nearly 10% of medical claims hospitals submit to payers are rejected or denied—translating to revenue loss of up to $5 million for the average hospital annually. Only 63% of denied claims are recoverable, and the administrative cost of following up on a claim denied by an insurer averages $188 per claim. But medical claim denials often are avoidable. The insurance peer-to-peer review (P2P) is one important strategy used to avoid or reduce claim denials and therefore prevent revenue leakage.
What can healthcare organizations do if their requests for prior authorization are denied for lack of medical necessity or other reasons by an insurer? Physicians/provider organizations can request an insurance peer-to-peer review.