Discerning the True Clinical Merit in Every Case Review

Identifying the right status for every patient is a crucial objective for healthcare providers.

From the patient’s perspective, these determinations are vital for providing the right level of care at the right time and place.

Accurate patient status determinations can also make a major difference in receiving the appropriate reimbursement for hospital systems, leading to more effective and efficient utilization review and case management processes. The alternative is a much more complex and costly process, riddled with unnecessary administrative work and subjectivity.

Providers can streamline their operations, reduce friction with payers, and lower costs by:

  • Making accurate patient status determinations based on clinical merit.
  • Providing payers with access to relevant information.
  • Using technology to optimize administrative operations. This gives time back to admins and clinicians (such as nurse case managers for utilization review) alike.

Focusing on the Most Complex Statuses and Cases

Some patients can easily be sorted into outpatient or inpatient status based on their specific symptoms and the severity of illness. There is clear clinical merit (definition: care considered medically necessary by a licensed provider) to these cases.

Other patients may fall along the borderline of inpatient and outpatient, however. And others might seem potentially incorrect based on comparing historical data analysis and predictive analysis to the individual patient’s status.

That’s especially important to note as payer denial rates continue to rise. Rev Cycle Intelligence explains denial rates for some Healthcare.gov marketplace payers reach as high as 80%.

Clear reasoning behind clinical merit and medical necessity determinations for each patient status is vital. It can be the first step to reducing escalations and claim denials. It can also help to effectively address escalations and denials when they inevitably arise.

Health system and hospital case management and utilization review can often be improved through effective, purpose-built technology. With the right tools in place, it’s easier to identify individual edge cases and complex issues facing certain patients.

Consider Dragonfly, Xsolis’ AI-driven platform that incorporates real-time analysis of patient data from their EMRs along with predictive analytics.

This solution empowers case management and utilization review staff to turn their attention toward the most complex cases. It also facilitates payer-provider communication and collaboration, with real-time data views that can be shared.

The result is utilization management processes that are more efficient, resulting in a more efficient facility or healthcare system . That means more time for clinicians to spend on complex cases and with patients overall. Cost savings are not uncommon to reach as high as 8.3X ROI in one year of use.

Incorrectly labeling a patient’s status potentially causes avoidable denials or leaves money on the table, respectively, for providers. And everything from providing initial documentation to fighting a denied claim leads to more time and money spent on the process. The costs of managing the claims and denial processes are high across the board. For example, 25% of hospital claim denials in 2021 were related to medical necessity and accounted for 30% of all denial write-offs resulting in significant losses for care already provided. With an estimated $33 billion in denial write-offs annually for hospital systems alone, that’s $10 billion in lost hospital reimbursement just related to medical necessity – and that’s on the conservative side.

In this context, a solution designed to identify the correct case status and supply relevant clinical information to payers is invaluable. It frees up valuable time for all staff involved in the process while also saving money.

Ready to learn how your hospital or health system can change for the better? Request a consultation today!