Smart Utilization – Reviews ‘by Exception’ and Beyond

Utilization review and case management teams have firm goals: effectively managing patient care and supporting the financial well-being of their organizations. Yet these teams are often understaffed and buried in clerical tasks that detract from a patient focus and increase the risk of denied claims.

Xsolis asked a crucial question about this process: What if not all patient cases need to be reviewed by staff? What if we could automate reviews for cases that are clearly inpatient and use saved staff hours for reviewing cases that teeter on the edge? These questions lie at the heart of Utilization Management “by exception,” a process that can only truly be deployed when an organization uses real-time analytics that assess patient information in real time and predict Level of Care.

UM by exception has become a reality for Xsolis clients – by using Xsolis’ analytics and Care Level Score™ (CLS) to segment and automate a select portion of inpatient vs outpatient determinations, each Xsolis client has the potential for UM by exception at their fingertips. This approach was first deployed by a large health system in the Southeastern US, who deployed it with their Medicare population (which comprised almost 28 percent of their patient population).

After assessing CLS accuracy thresholds within their patient population, they could perform minimal- to no-touch reviews on approximately a third of their Medicare population. This meant that well over 10,000 cases were automatically reviewed, freeing up scarce utilization management resources to engage with cases which were less clearly inpatient or outpatient – what we term “gray zone cases.” This approach had a huge impact on the system’s outcomes, financial performance and staff workload. To learn more about this approach, view our recent webinar “Managing by Precision”.

Poviders have also seen the opportunity to use Xsolis’ analytics to create a shared framework between their hospitals and commercial payers, with both parties realizing the benefits of data-driven alignment. Within this framework, XSOLIS’ utilization review platform, Cortex, is used by payer staff to review and authorize cases that are escalated to them directly from the participating provider. Through Cortex, payer staff have access to the same real-time predictive analytics and patient insight, making the review process a clear and streamlined determination of medical necessity. This approach is changing the way payer and providers across the nation collaborate, with network effects extending across the industry.

To learn more about this approach, get in touch with our team today.

This post is adapted from our white paper, “Unpacking the State of Utilization Management”.