Effective care transitions and heightened operational efficiency have long been the trademarks of internal utilization review and case management teams – the more effective the staff, the less their work is recognized. This often means they are overlooked as an integral part of the care continuum and underinvested in despite their value to both patients and the hospital revenue cycle. However, new computing technology and data analysis techniques promise to increase the visibility and effectiveness of case management while ensuring case managers are equipped to do their best work, more consistently.
While case management focuses on ensuring the highest quality of care and creating a support structure for each patient, case managers or utilization review staff are also tasked with overseeing the medical necessity of the care patients receive. An inherently patient-centric assessment – each patient needs the right care, at the right time – the right medical necessity determinations produce important financial outcomes for hospital executives: if patients aren’t admitted and discharged in the right status (inpatient or outpatient) at the right time, claims submitted to payers are denied, leading to lost revenue and audit risk.
Technology plays three fundamental roles in transforming case management from process-driven to performance-driven: prioritizing time spent on cases, refining the review process, and supplementing the expertise of the care team to ensure more consistent clinical decision-making.
Patients are often reviewed at the beginning of each shift; however, status changes can happen in the blink of an eye. If a patient’s condition changes and they meet inpatient admission criteria without a timely review, revenue is put at risk. With predictive analytics that pick up potential status changes, patients can be flagged for review and nurses notified immediately, seamlessly aligning staff availability with patient necessity. Additionally, these same analytics can prioritize patients upfront based on risk, ensuring that staff focus their immediate attention on cases most likely to change status. This workflow efficiency not only saves time, but means that more time is spent caring for patients, not sifting through records.
Utilization review and case management processes have been historically manual. With the reduction of paper charts through EMR utilization, skilled nursing staff are often required to sit at a computer to hunt through piles of data for critical patient information. These manual processes – “snapshots in time” – don’t offer the continual stream of data that allows staff to analyze patient conditions in real-time or to be automatically notified as patient conditions change. Advances in cognitive computing now allow predictive analysis of high-risk patients: historical data coupled with current status paint a picture of each patient’s condition far more accurately and quickly than has ever been possible. The result? Each patient is placed in the appropriate status as early as possible during their stay.
Case managers are experts at understanding medical necessity requirements at the payer level and applying respective guidelines to each individual patient situation. However, increased scrutiny on reviews from Medicare and commercial payers means that medical necessity determinations need to be based not only on staff expertise, but must be supplemented by data that supports the clinical merit of the case, meticulously documented and formatted for each specific payer. A lack of standardization across payers means that much of this burden falls to each case manager, increasing workloads and decreasing time spent on more fundamental tasks. By integrating with EMR systems and criteria already in place, technology solutions can bridge this gap by ensuring that more consistent decisions are made, creating a more complete clinical picture of each patient, and allowing case managers the freedom and flexibility to trust their judgment on each case, with necessary clinical documentation served up immediately to support each determination.
Technology Is a Vital Asset for the future of case management
Automated data analysis and computing technologies will continue to play a vital role in the future of case management and innovative hospitals and health systems nationwide are already embracing technology that transforms the way they approach utilization review and case management, enabling staff to work more effectively and eliminate the operational hurdles that put revenue at risk.