If a hospital has a higher-than-expected level of PPCs, why would a health insurance plan think that the hospital can find ways to reduce the level of PPCs

If a hospital has a higher-than-expected level of PPCs, why would a health insurance plan think that the hospital can find ways to reduce the level of PPCs, and thus reduce unnecessary utilization of services, and reduce the length of stay?

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Expert Solution

Utilization management is known to be the medical necessity evaluation,efficient and appropriate use of health care services with different procedures and facilities under the provision of the applicable health benefits plan.It has three types.

Concurrent review that perform during course of care and treatment
Prospective review that performed rendered care to eliminate/reduce unnecessary services
Retrospective review conducted after completion of services.

Potentially Preventable Complications (PPCs) is a method that uses present on admission (POA) indicator for the identification of complications on secondary diagnoses that arises after admission.Hospital has a higher-than-expected level of PPCs,and health insurance plan think that the hospital can find ways to reduce the level of PPCs,because with respect to a person it is a harmful event that gives negative outcomes.It creates infections or even complications during surgeries.It occurs after persons admission to a hospital or if there is long term care facility.It also results for a lack of care or the treatments in the hospitals during course.Texas do care about PPCs due to its cost,value and quality.

In this methodology such as A/E(actual and expected rates or ratio) ratios,POA(present on admission),Software and data are used.PPC programs are used in quality based program,DSRIP and DSHS.They are under hospitals control and thus reduces unnecessary utilization of services, and reduce the length of stay.

keosha answered 2 years ago

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