Managed Care Quality: Hearing Before the Subcommittee on Health and Environment of the Committee on Commerce, House of Representatives, One Hundred Fifth Congress, First Session, October 28, 1997, Volume 4 |
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Page 8
... utilization review nurse consulted the pediatrician on call , related the symp- toms and conveyed that she had ruled out respiratory distress . Based on inadequate information provided by the nurse , the pediatrician told her to tell ...
... utilization review nurse consulted the pediatrician on call , related the symp- toms and conveyed that she had ruled out respiratory distress . Based on inadequate information provided by the nurse , the pediatrician told her to tell ...
Page 36
... review process . An additional six states require NCQA accred- itation for ... Utilization Management : Does the plan use sound clinical evidence and ... utilization ? Are decisions made by individuals with sufficient expertise to make ...
... review process . An additional six states require NCQA accred- itation for ... Utilization Management : Does the plan use sound clinical evidence and ... utilization ? Are decisions made by individuals with sufficient expertise to make ...
Page 59
... review for utilization / quality assessment • Retrospective review for " medical necessity " • Retrospective review for coverage issues • Aggregate profiling of provider network to assess and determine normative statis- tical standards ...
... review for utilization / quality assessment • Retrospective review for " medical necessity " • Retrospective review for coverage issues • Aggregate profiling of provider network to assess and determine normative statis- tical standards ...
Page 60
... review was commonly used before managed care gained prominence . As with ... utilization ( e.g. lengths - of - stay , admissions per thousand , referral ... Utilization . " Within this section , the author notes that : " As growing plans ...
... review was commonly used before managed care gained prominence . As with ... utilization ( e.g. lengths - of - stay , admissions per thousand , referral ... Utilization . " Within this section , the author notes that : " As growing plans ...
Page 61
... utilization and financial information available from which they can make ... review for " continued stay " for hospitalized patients for earlier dis ... management of decisions regarding the care of a patient at hand . Physicians have ...
... utilization and financial information available from which they can make ... review for " continued stay " for hospitalized patients for earlier dis ... management of decisions regarding the care of a patient at hand . Physicians have ...
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Common terms and phrases
accreditation American appropriate believe BILIRAKIS bill breast cancer Chairman Charlie Norwood choice clinical committee CONGRESS THE LIBRARY consumer protections cost coverage decisions denied dental benefits DINGELL doctors emergency employers enrolled enrollees ensure ERISA plans ERISA preemption federal fee-for-service fee-for-service plans GANSKE going health care providers health care system health insurance health plans health professionals hearing HEDIS HMOs hospital IGNAGNI important issue legislation liability LIBRA LIBRARY OF CONGRESS managed care organizations managed care plans mandates mastectomies MCOs measures Medicaid medical necessity Medicare MILLER NCQA NORWOOD O'KANE OB/GYN occupational therapy option PARCA Patient Access patient protections PEENO percent performance physicians plan's practice premiums PREPARED STATEMENT problems procedures purchasers quality assurance quality improvement RARY referrals RESS result specialists specific survey Thank tient tion treatment utilization review women
Popular passages
Page 189 - While on the one hand, this serves the valid goal of ensuring that the plans' resources are not depleted by flurries of litigation, on the other, it leaves mistreated members with little or no recourse. The Corcoran court suggested that change might be in order: [T]he world of employee benefit plans has hardly remained static since 1974. Fundamental changes such as the widespread institution of utilization review would seem to warrant a reevaluation of ERISA so that it can continue to serve its noble...
Page 63 - We should strive to create conditions which enable physicians to be open, fair, compassionate, and caring -• indeed to be the professionals we train them to be — with every patient equally. We should provide uniform structures and operations to ensure that the health plan does not amplify existing fear, pain, suffering, anxiety and confusion. Justice in health care means that there should be no financial, geographical or discriminatory barriers to a levels of care that provide relief or care...
Page 139 - Health status-related factor means health status, medical condition (including both physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence) and disability. Individual health insurance coverage means health insurance coverage offered to individuals in the individual market, b'ut does not include shortterm, limited-duration insurance.
Page 173 - Third party payers of health care services can be held legally accountable when medically inappropriate decisions result from defects in the design or implementation of cost containment mechanisms, as, for example, when appeals made on a patient's behalf for medical or hospital care are arbitrarily ignored or unreasonably disregarded or overridden.
Page 173 - ... from all those responsible for the deprivation of such care, including, when appropriate, health care payers. Third party payers of health care services can be held legally accountable when medically inappropriate decisions result from defects in the design or implementation of cost-containment mechanisms...
Page 144 - ... (I) No specific payment is made directly or indirectly under the plan to a physician or a physician group as an inducement to reduce or limit medically necessary services provided with respect to a specific individual enrolled with the entity.
Page 171 - Cir.), cert, denied, 506 US 1033 (1992). In the Corcoran case, a couple alleged that the negligent actions of their ERISA plan's utilization reviewer had caused the death of their unborn child. After the mother's physician had recommended hospitalization during her high-risk pregnancy, the utilization reviewer refused to authorize the inpatient stay. Instead, the reviewer authorized part-time home nursing care. Several weeks later, during a time when no nurse was on duty in the mothers home, the...
Page 39 - Committee believes that an important objective of a good managed care plan should be to help members become active partners in their health care decisions. To do so means that the health plan must equip members to make informed choices about their care. The Committee's objective in defining this domain was to develop measures that would assess how effectively health plans accomplished that result. • Use of services: How a health plan uses its resources is a signal of how efficiently care is managed...
Page 37 - A set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. The performance measures in HEDIS are related to many significant public health issues such as cancer, heart disease, smoking, asthma, and diabetes. HEDIS also includes a standardized survey of consumers...
Page 173 - California court subsequently held that an insurance plan's decision not to authorize continued inpatient hospitalization for a depressed and drug dependent patient could form the basis of a wrongful death action against the plan and its utilization reviewer. Wilson v. Blue Cross of Southern California. 271 Cal. Rptr. 876 (Cal. App. 1990). Although the patient's physician had recommended a three to four week hospitalization, the utilization review company denied coverage after twelve days of hospitalization....