Struggling with Inconsistent Workflows, Manual Processes & Strained Health Plan Relationships

Heather Wagner, Director of Utilization Review and Case Management, and Brandy Martin, Utilization Registered Nurse Educator at Beacon Health System, encountered substantial challenges in their utilization management (UM) workflows. Their teams were constrained by manual paper-based processes, resulting in inconsistent workflows and strained relationships with their health plan partners. Additionally, siloed and disparate patient data hindered cohesive decision-making across clinical teams. This placed their utilization review (UR) nurses at a disadvantage, unable to work at the top of their license and make data-driven decisions for Beacon Health’s patients.

Striving to Enhance Efficiencies, Elevate Patient Outcomes & Boost Revenue

“As UM leaders,” Brandy emphasizes, “We consistently consider the 4 Vs: Volume, Variability, Vitality, and Viability.” Beacon Health consistently manages a high volume of critically ill patients with chronic illnesses, underscoring the need for a more holistic approach to patient care. However, the application of criteria by Heather’s and Brandy’s teams to make medical decisions was subjective, resulting in variability in clinical decisions. Given the clinical expertise required of UR nurses, it was imperative for Beacon Health’s clinical teams to use technology to enhance their experience, rather than relegating them to solely “checking the boxes” to meet clinical review criteria.

Heather and Brandy aimed not only to improve UR workflows and operations but also to strengthen the health system’s revenue for sustained operations. This involved building rapport with their health plan partners to ensure a mutual understanding of all clinical decisions. Recognizing the potential for improvement, Beacon Health implemented the CORTEX platform (now Dragonfly) in May 2019, shortly before the onset of the COVID-19 pandemic.

Turning Vision into Action with Xsolis

As part of the implementation process, Xsolis team members provided onsite assistance to help the Beacon Health teams develop workflows aimed at optimizing their daily operations. This optimization represents an ongoing journey to ensure that they are consistently delivering the best care for their patients while building strong relationships with their health plan partners.

A major milestone for Heather’s and Brandy’s teams was the adoption of the Care Level Score™ (CLS™). The CLS is a numerical calculation that gauges the likelihood of appropriate patient status based on a comprehensive analysis of patient data, driven by Xsolis’ real-time predictive analytics and machine learning. By incorporating the CLS into their daily workflow, Beacon Health’s UR nurses are provided with a clear starting point for patient prioritization. Heather highlights that the Xsolis platform “consistently consolidates all patient data in real-time to support our nurses in making informed clinical decisions.”

Heather emphasized another key benefit of collaborating with Xsolis: Beacon Health has significantly strengthened the relationships with their health plans. With the goal of achieving a seamless workflow, Beacon Health is now connected through the Xsolis platform with three of their primary health plans. Not only do the Beacon Health teams now directly escalate clinicals within the platform, but they also utilize Precision UM alongside a large national health plan. Precision UM automates inpatient determinations agreed upon by both parties (Beacon Health and the health plan), eliminating the need for unnecessary back-and-forth communication via faxes, emails, or phone calls

Enhanced staff efficiency and improved collaboration with health plans have resulted in a 22.1X ROI from April 1, 2019 to December 31, 2023, as well as a 34.2% improvement in their observation rate. Additionally, $7.4 million has been recovered with Xsolis Denial Services since May 2019.

Ensuring the “Right Person, Right Patient, Right Level of Care”: Beacon Health’s Transfer Center Story

In March 2023, Beacon Health faced an urgent need to reevaluate their approach to case management due to substantial Medicare Advantage (MA) denials. Initially, they adopted a conservative strategy for inpatient admissions, advising their physicians to start patients in an observation level of care. Heather and Brandy collaborated with their transfer center to offer care level recommendations to admitting providers while patients were in the emergency room, guided by the Care Level Score (CLS) displayed in the Xsolis platform. Although the implementation proved challenging, with adjustments made weekly, their persistence yielded positive results. Monthly MA denials decreased from 50 to 10, demonstrating the effectiveness of their new approach. Furthermore, they can now appropriately downgrade patients, preventing them from incurring ancillary charges. “We’re now able to work more collaboratively,” Brandy states, “ensuring that the right provider, patient, and level of care are aligned for optimal patient outcomes.”

Another successful initiative implemented by Beacon Health in collaboration with one of their commercial health plans is clinical rounds. Biweekly, Beacon Health physician advisors meet with the health plan medical directors for face-to-face, peer-to-peer reviews. This collaborative approach has significantly improved alignment between the two organizations. According to Heather, “I truly perceive this as the future of collaboration between payers and providers.”

¹ ROI projections are estimates based on similar system information and averages over the first 2 years of utilization. Such ROI projections do not guarantee future results. Actual ROI will vary based on various conditions and factors for each customer, including, but not limited to, client baseline information, best practice utilization of the products, etc.