The utilization review process is designed to help hospitals determine the appropriate level of care and care setting for patients based on medical necessity. While this process is an expense for ...

The UR process is necessary to treat patients. Hospitals cannot admit Medicare beneficiaries without a UR plan. The Code of Federal Regulations (42 CFR 456 and 42 CFR 482.30) and the Medicare ...

“Today, utilization management is too often being performed on decades-old technology, creating inefficiencies and affecting staff performance,” said Adam Sabloff, VirtualHealth CEO.

New data-guided approaches like precision utilization management, move beyond the concept of ‘UM by exception’ to apply real-time data and insight selectively within the review process ...

A recent opinion from the Commonwealth Court of Pennsylvania has changed the rules for Utilization Review and thrown open the doors to a new class of litigants. In Keystone Rx, LLC v. AmeriHealth ...

Keystone Rx appealed, arguing that the utilization review process unfairly excluded pharmacies where their compensation was concerned, in violation of their due process rights. The court looked to ...

Sunwave also anounced the launch of its BDR (Business Development Representative) mobile app, designed to help business development representatives in the behavioral health sector network and manage ...

Baer, who was first elected to the bench in 2003, took over the leadership role after former Chief Justice Thomas Saylor agreed to step down as the court's leader last month—nearly one year ...

It not only transforms utilization management, but it is also designed to enhance the entire medical review and clinical process by offering the ability to connect all parties involved within the ...

On January 25, 2022, the U.S. Court of Appeals for the Second Circuit affirmed a lower court ruling that the Secretary of HHS violated the due process ...