Hospital utilization management can lead to substantial benefits for providers, payers, and patients, when it is efficient and effective.
Hospitals must focus on positive patient outcomes and better relationships with payers in utilization review, however. Utilization management doesn’t automatically lead to positive results, as every provider organization knows. The right approach can incorporate payer needs like determining medical necessity as well as support individual and population health.
Principled and Efficient Hospital Utilization Management is Crucial
The right strategy and technological support can empower providers to quickly determine which cases need the most attention. Then, those healthcare professionals can spend valuable time working with those higher-risk patients.
Specialized technologies that leverage artificial intelligence and machine learning can capably handle straightforward case management tasks. This leaves clinicians with the additional time needed to make the most of their deep knowledge and experience. Laser-focused prioritization on the most critical cases has become especially important since patients are sicker – at least 10% sicker between 2019 and 2021 alone, according to an American Hospital Association report – due to delayed and avoided care during COVID.
Overall, consistently strong hospital utilization management plans can have a widespread positive influence at the population health level. Time-saving workflows consistently reduce administrative burden to create more efficiency for the healthcare industry’s staff-stretched workforce, saving time that can be reallocated toward patient care. That empowers hospitals to make a broader impact in the communities they serve over time.
Using resources more efficiently and identifying health issues before they become more serious leads to major benefits. It’s possible to spend less in the big picture and deliver better patient care and outcomes — and that’s something that patients, providers, and payers can all agree on.
The Right Hospital Utilization Management Strategy and Tools are Crucial
Utilization review (UR) in healthcare can also be filled with challenges that negatively impact revenue, as the Healthcare Financial Management Association explains. Those issues span across the entire process: from misaligned department organization, to a lack of understanding of regulatory guidelines versus clinical criteria, to inefficient processes that increase denials and observation rates.
Clinicians and admins both understand how utilization review can drain resources when not structured effectively. When nurses are only relying on criteria-based UR solutions, for example, they can’t truly use their knowledge or skills, nor are they empowered to make more accurate and consistent data-driven decisions.
Fortunately, as the HFMA suggests in the same article, “an assessment and evaluation of the utilization review (UR) process will uncover numerous opportunities to improve,” and XSOLIS represents a new path forward for utilization management and review. Our CORTEX® platform is the first and only solution to use real-time predictive analytics to continuously assign an objective medical necessity score and assess the anticipated level of care for every patient.
CORTEX conducts in-depth reviews of all cases, helping point clinicians toward those requiring the most attention. Many customers describe these benefits as “like having an assistant.” Instead of endlessly combing through EMRs, nurses and doctors can quickly see the most relevant details.
That information can also be quickly and easily shared with payers. CORTEX provides access to reviewers on the payer side, streamlining the approval process. When providers and insurers both agree on patient status standards set in CORTEX, approvals can be automated as well.
Learn more about making hospital utilization management a positive for your organization. A better way is possible. Schedule a CORTEX demo today!