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Monday, March 17, 2014
  Clinical Accuracy Spoken Here  

Population Health: Be Alert for Duplicative Services

MCOs reserve the right to review a daily itemized bill for the patient's entire inpatient stay, to evaluate for:

  • Duplicative services such as radiologic
  • Overuse of medications

MCOs with all types of payer contracts may consider this option for reasons including:

  • MCOs with case rates may have exceptions for extensive trauma or catastrophic events
  • MCOs who pay per diems may audit charges with a view toward contract renewals and controlling increasing rates
  • MCOs who pay a percent of charges need to assure that those charges are reasonable and necessary

[Reference: Population Health, Module B, Concurrent Review]
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  Excellence in Case Mgmt  

Population Health: Purpose of Concurrent Review

MCO CMs conduct concurrent review to determine:

  • Medical necessity throughout the length of stay
  • Level of care appropriateness
  • Quality of care issues
  • Transition planning needs
As the MCO case management focus moves from prior authorization to concurrent review considerations, the MCO CM role mimics that of the HCM in many respects.

[Reference: Population Health, Module B, Concurrent Review]
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  Improving Patient Care...  

Population Health: Reason for Readmission?

Not all hospital readmissions can be blamed on inadequate transitions of care or lack of discharge planning.

Readmissions are either planned or unplanned. The next question is whether or not the reason for readmission was related to the reason for the initial hospital stay.

[Reference: Population Health, Module C, Transitions of Care]
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Tom RasmussenTom Rasmussen
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