Clinical Intelligence in Healthcare Risk, Compliance, and Insurance Investigations - Tapa blanda

Sinopsis

One event. Several decisions. One record beneath them all.

A serious hospital event can become a patient safety review, a reporting decision, a compliance question, and an insurance claim in the same week. A claim file can become a medical necessity review, a coding audit, and an SIU referral. Each desk asks a different question of the same clinical record, and each can reach the wrong answer when the medicine is misread, the reporting clock is missed, or a finding is stated with more certainty than the evidence allows.

Clinical Intelligence in Healthcare Risk, Compliance, and Insurance Investigations is a daily reference for the professionals who make those decisions. Michelle Carroll, Founder and Chief Clinical Strategist of Lexcura Summit, draws on more than four decades in healthcare to apply the seven pillars of the Lexcura Clinical Intelligence Model: Record Integrity, Baseline Profiling, Imaging Analysis, Timeline Reconstruction, Standard of Care Review, Regulatory and Compliance Overlay, and Causation Mapping. Every finding is stated as Established, Supported but disputed, Inferential, or Unresolved, so the person with authority can act on what the record actually shows.

Inside, readers will find:

• The first seventy-two hours: preservation, privilege, disclosure, and reporting clocks
• Serious incident investigation, root cause analysis, and corrective action that works
• Compliance programs, overpayments, the 60-day rule, and board reporting
• Insurer notice, coverage, and claims-made policy questions
• Medical necessity, coding, clinical documentation, and payment integrity reviews
• Fraud, waste, and abuse, SIU referral thresholds, and fair use of surveillance
• Three complete worked cases: a hospital deterioration with delayed reporting, a physician's admission pattern under SIU review, and a catastrophic injury claim with conflicting records
• Desk guides, intake and records request matrices, deadline tables, a glossary, and a table of authorities

Written for hospital risk managers, patient safety and compliance officers, incident investigators, claims and SIU professionals, payment integrity analysts, counsel, and boards, this book gives every desk one evidence architecture, keeps uncertainty visible, and helps decisions withstand regulators, auditors, insurers, and courts.

Part of the Clinical Intelligence series by Michelle Carroll.

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