Blog

February 27, 2017

A Minnesota District Court judge’s ruling “has huge implications for wrongful denial of coverage cases,” and may have long standing implications for the external review industry.[1] The case of James Linn et al. v. BCBSM, Inc., addressed a plaintiff seeking damages against a health plan for its initial refusal to pay for proton-beam radiation therapy […]

adverse determination
cancer
court
ER
experimental treatment
external review
lawsuit
litigation
MAXIMUS
medical necessity
Minnesota
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February 17, 2017

Genomics and Utilization Management Genetic testing has revolutionized healthcare by providing clinicians with the tools necessary to predict disease.  Sequencing and mapping DNA and other bioinformatics brings huge potential to medicine. Cancer, for example, can be hereditary. Knowing one’s predisposition to cancer could mean the difference between life and death. In the case of Li-Fraumeni […]

cancer
genomics
hereditary
personalized medicine
UM
utilization management
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February 6, 2017

Should an Independent Reviewer’s Identity be Disclosed? Mention reviewer anonymity and you’ll uncover strong opinions for and against the practice. It’s hard to find a middle ground on the matter of whether to reveal an independent reviewer’s identity. And even though the Centers for Medicare and Medicaid Services (CMS) do not permit insurers to “provide […]

anonymity
ER
external review
independent review organization
IRO
reviewer
transparency
UM
utilization management
utilization review
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February 3, 2017

Providing Transparency in External Review Transparency in healthcare is an important part of the Affordable Care Act (ACA). And even though ACA will either be dismantled entirely or undergo significant changes with the new administration, it’s likely that transparency will remain a key issue. Additional legislation, including the Mental Health Parity and Addiction Equity Act […]

accreditation
external review
IRO
MHPAEA
NAIRO
transparency
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