Utilization review forms the first line of defense for revenue sensitive cases for hospitals; physician advisors serve as the backbone and second line for cases requiring greater scrutiny or closer inspection. While undertaking a second-level review, a physician advisor (PA) brings to bear years of clinical experience and regulatory expertise – it is a highly skilled job and PAs are often in short supply.
Typically, utilization review staff use one of two methods to determine if the case should be escalated to a physician advisor: their own clinical judgement or technology. While the former has been relied upon for years, technology is increasingly used to support physician advisors. And if the right technology is put in place, escalations to PAs should decrease, not increase. It’s not about casting a wider net – it’s about using technology as a double-layered approach: first, to ensure that the right cases are identified and reviewed by nurses up front, second, to ensure that only the right cases are escalated to PAs for review.
Base Inpatient Determinations on Clinical Merit
Inpatient status should be determined by demonstrated medical necessity. Period. Technology should be aimed at streamlining the process of accessing and assessing the vast amount of information required to make and support a clinical judgement. Analytics models must take into account the way a physician thinks, rather than the judgement from a payer or provider case-by-case.
Use a Two-Tiered Approach for Second Level Reviews
With XSOLIS’ precision utilization management platform, Cortex, utilization review staff receive real-time updates on changes in patient acuity or status and can review cases with a holistic, complete picture of the patient – before the need for a physician advisor’s review. This proactive stance on the front end reduces the number and frequency of cases requiring a PA review. For instance, one early XSOLIS client saw an average decrease of 36% in the number of cases escalated to physician advisors across a nine-month period after their go-live, a trend that has continued throughout their partnership – this client simultaneously saw both a decrease in their observation rate and a decrease in their medical necessity denials.
Make Second Level Reviews Count
Physician advisors are a specialized, highly effective resource in your revenue integrity efforts – and their services should be used effectively, not recklessly. As you look to your physician advisors as strategic assets, ensure that the technology you employ makes their job easier rather than creating more of it. Whether you have an internal physician advisor model or an external service, ensure your technology and processes make those second level reviews count.
For an example of how Xsolis serves utilization review staff and physician advisors, read our case study on MultiCare Health System in Washington state.