Can Analytics Reframe the Payer-Provider Relationship?

Sherri Ernst, Revenue Integrity & Utilization Management Officer at Covenant Health, knew the system was broken. Claims that met criteria were still being denied time and again, requiring her staff to devote precious time and resources to justifying and appealing these cases. Shortly after Covenant Health partnered with Xsolis, Sherri approached Xsolis about an idea she had: why couldn’t the Xsolis platform, with its real-time predictive analytics that form a full clinical picture of each case, be made available for use by payers? If she was able to work with the payers to determine the clinically-relevant data points through a unified platform, both parties could move towards a common ground for determining medical necessity. This proposal struck our team as novel, and much needed.

For too long payers and providers have stood at odds. The administrative costs of the appeals process weigh heavily on both sides. Guidelines haven’t proven themselves valuable in hemming in these costs either, as the application of guidelines is often inconsistent and at times, indefensible. However, thanks to Sherri, today it doesn’t have to be this way.

Xsolis today announced a new approach to utilization management that promises to realign how hospitals and insurers assess the medical necessity and appropriate status for every patient: we are now partnering with client providers to set up custom Partner Portals which are used by their participating payers to streamline communications and create an objective, data-driven process for determining appropriate hospital-based care.

When hospitals deliver medical records, they often send the entire record after they complete their clinical review, forcing the payer to complete an entirely separate clinical review on the same patient. This manual process, combined with the administrative burden of managing both reviews and denials and the financial implications of duplicative work, often causes frustration for both payer and provider. However, the Xsolis Partner Portal paves the way for true UM by exception by analyzing the entirety of each medical record and scoring every patient on medical necessity – if the scored outcome is within a certain threshold determined by both payer and provider as meeting the requirements for either inpatient or outpatient status, no clinical review is required and the case is considered final. This process doesn’t replace the clinical expertise of the physician or nurse, it merely enhances that expertise by directing staff attention towards the cases that aren’t clearly inpatient or outpatient – the “gray zone” medical necessity determinations.

As payers and providers continue to adopt better processes and technology that reduce the administrative burden on their staff and allow their clinical experts to focus time on their patients, the transformative nature of this approach will continue to be felt across the industry. Due to the integrated delivery system within healthcare today, it is vital for payers to facilitate and manage strong relationships with each of their providers – no longer at odds, both parties have a role to play in creating a better and more efficient healthcare system.

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