Controlling Costs and Changing Patient Care? The Role of Utilization Management (1989) / Chapter Skim
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Appendix C - Utilization Management in Peer Review Organizations
Appendix C - Utilization Management in Peer Review Organizations
Pages 246-249
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From page 246... ...
The varieties and complexities of PRO review depart considerably from the types of prospective and retrospective review typical of the private sector. · First, preadmission review by PROs is much narrower in scope than it is for most private programs.
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From page 247... ...
Each contract period Is covered by an extensive scope of work that lays out the work expected. This scope of work Is accompanied by an array of ~ In 1972, Congress recognized that the burden of a retrospective claims denial under Medicare fell unfairly on the beneficiary who incurs Medicare costs as a result of orders and charges generated by the physician and hospital.
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From page 248... ...
The law states that no practitioner and no provider can be held civilly liable under any law of the United States or of any state on account of action taken in reliance upon PRO norms, criteria, and standards, provided that he or she otherwise exercised due care. Enacted in 1972 and intended to discourage expensive defensive medicine and encourage cost containment, the provision was reenacted verbatim in the PRO law.
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From page 249... ...
Gosfield, Alice, "PROs: A Case Study in Utilization Management and Quality Assurance," 1989 Health Law Handbook, New York: Clark Boardman Co., Ltd., 1989. Physician Payment Review Commission, Annual Report to Congress, Washington, DC, 1988.
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