The Mihalik Blog

Medical Staff Bylaws

Hospital Medical Staff Bylaws seem to be getting more attention lately. You can find one example here.

The Joint Commission’s standards for Focused Professional Practice Evaluations (FPPE) and Ongoing Professional Practice Evaluations (OPPE) seem to be generating much of the interest.

The OPPE, in particular, forces hospital medical staffs to develop a process to gather objective data and to use the data in pre-established and methodologically sound ways to evaluate practitioner performance trends that affect clinical care and patient safety.

Just recently I and another consultant from The Mihalik Group developed a set of model Medical Staff Bylaws and Rules and Regulations for the United States Department of Veterans Affairs. Once approved by VA leadership, the bylaws will be made available to all VA facilities. This was an exciting project! It felt really good to be able to take TJC requirements and VA requirements and meld them into a document that provides a framework for medical staff functioning.

If you have concerns about whether your medical staff bylaws are up-to-date we can help.   

Denials and Appeals

For years now, I’ve been reviewing coverage denials issued by health plans and appeals of those denials.  I’ve noticed a few recurrent themes.

 

Providers, such as hospitals and practitioners, often receive denials by not following contractual requirements for prior authorization and concurrent review.

 

Providers often fail to have a denial overturned on appeal by not specifically focusing on the specific reasons for the denial. 

 

I can’t tell you how often I see a health plan receive an appeal that is nothing more than a copy of the medical record without so much as a cover letter.  Just as frequently, I see hospital staff send the same cover letter (with typographical errors and all) for each and every appeal.  I’m not kidding.

 

Providers stand a better chance of successfully appealing a denial if the request for the appeal includes a clear clinical rationale that addresses the specific reasons the denial was issued. 

 

If your denial rate is higher than you’d like or your rate of successful appeals is lower than you’d like, we can help. 

 

The Mihalik Group can manage the entire appeals process.  If you’d like more information on how we do check out our AppealSuccess™ product on our web.  Because 50% of hospitals are currently operating at a deficit, we’ve structured the appeals management service on a contingent fee basis, so there are no out of pocket expenses.  If we’re successful, we get paid—and so do you! 

 

We can also help reduce your denial rate with our DenialPrevention™ program.  We’re happy to start here but I actually think it makes more sense to let us manage your appeals first.  After we’ve done that for a while and have an understanding of what is causing your denials, we can more efficiently analyze internal processes and prescribe solutions.  What’s more, you can pay for the entire DenialPrevention program from the money we recover by managing your appeals.

 

If you want more information you can fill out this form or, for personal attention, you can write to me at gary@themihalikgroup.com.