Three Approaches to Innovation in Utilization Management
by XSOLIS Insights, on Oct 16, 2017 6:00:00 AM
Healthcare in the United States continues to retain a reputation of being notoriously slow to innovate, even as providers, payers, and technology companies across the nation rush to solve many of the pressing issues that curtail quality and effective care delivery.
The need is real and the opportunity is vast, yet many leaders in the realm of utilization management have begged the question: “where do we start?”
Case management and utilization review have and will continue to benefit from several definitive approaches that seek to enable higher quality care, reduce costs, and create a framework for strategy and innovation that drive progress in the sector.
Aligning Clinical, Financial and Regulatory Interests
As a crucial mediator between the seemingly siloed interests of compliance, revenue cycle management and optimal care quality, utilization managers have the unique opportunity to create greater alignment between payers and providers. Equipped with the knowledge and expertise to effectively help determine level of care and medical necessity, each case manager or CDI specialist rely on data and patient insights that complement their extensive knowledge on the differences in regulation, types of service, and system requirements that so often misalign incentives and lead to unfavorable outcomes. Nurses and utilization management staff serve as the front lines of value-based care and should be empowered as such.
Utilizing the Right Resources, at the Right Time
A lack of clarity is often one of the biggest barriers facing utilization management staff – whether a change in status, an unmet need, or unrecognized clinical context for the patient, a lack of insight into people and processes can create a cascading effect that decreases the quality of service. Leading providers are realizing that education, oversight, and technology often translate to better outcomes. Hospital executives have increasingly mandated the need for concentrating resources where they will have the greatest, timeliest impact and utilization management teams are rushing to adapt.
Focusing on the Metrics that Matter
A laser-like focus on the most pertinent clinical facts relative to status decisions allows utilization review experts to ensure they provide not only the highest quality of care, but maintain levels of compliance that exceed industry norms. Increasingly, these experts turn to technology to assess and identify acuity and trend data that lead to better outcomes. By getting things right up front, revenue risk declines, care is provided quickly and efficiently, and compliance reaches its highest levels.
While all new priorities require enthusiasm and energy, concentrating efforts behind these three approaches can help utilization and case management leaders see tangible results quickly.
And as they continue to educate and support their staff to deliver these results, the next step lies in adopting the technology, processes and personnel that prioritize innovation and set the foundation for the healthcare of the future.