What’s Happening Downstream? Creating Data-driven Utilization Review

Ensuring successful Utilization Review within a hospital or hospital system is a multi-pronged approach. In order to produce impactful results, leaders must empower their teams to continuously innovate and iterate. How? By using data to inform one small change after another. We took an in-depth look into how one system has made small and large changes that have led to big results, and why the winding road has been both challenging and rewarding.

In 2018, Legacy Health, a non-profit hospital system that operates seven hospitals in Portland, Oregon, transitioned to a centralized utilization management model. Shortly thereafter, Tracy Neidetcher transitioned into a role as Manager of Utilization Management and was tasked with drilling down into the financial data and outcomes associated to utilization management.  In a recent webinar, Tracy Neidetcher, MSN, MBA, RN, NE-BC recalled, “defining the step-by-step process Legacy Health used was key to future success” as she shared the steps she took to make data actionable for her team.

Seeking Better a Better Path Forward

Neidetcher explained, “exploring how connecting data – on denials, documentation issues and more – to daily work was pivotal in realizing the necessary culture and behavior changes needed in the UR space.” However, unpacking how administrative task automation can refocus staff time on patients, process and performance had its pain points.

“UR would complete their work, but there was no connection to the back-end environment, so the team wasn’t up to date on the downstream results of their decisions,” Neidetcher continued. There was a realization that teams were operating in silos, which led to inefficiencies with workflow processes. Additionally, there was no formal education provided to staff on medical necessity and intensity of service, which added to the inconsistencies. Regulated audits uncovered many areas of opportunity with big financial implications. Tracy quickly understood how great their need was to understand UM productivity and its impact on the hospital system.

Initiating Root Cause Analysis

Visibility into data was minimal, specifically the correlation between real-time decisions and retrospective outcomes. This lack of visibility into data was leading to denials and write-offs that burdened the system financially. Neidetcher believed “variability existed among staff due to the tools used, or lack thereof.” It was evident that the UM team could no longer work independently of the hospital Revenue Cycle.

Tracy and her team took a forward-thinking approach to retrospective data on claims. They initiated a full root cause analysis by looking at every single write off labeled with medical necessity where nurses, for the first time, could offer written narratives about each of their patients and determine the foundational cause to each write-off. A surprising offshoot of this new, monthly procedure became very apparent: some of the medical necessity root causes were not inside the span of UM, but rather controlled by outside factors such as payer contract terms. They needed to include their Revenue Cycle team in their review sessions to highlight what they were seeing, and identify opportunities for improvement across teams.

Translating Data into Action:

They also implemented a new technology: the CORTEX Platform, now known as Dragonfly Utilize, which opened the door to data: predictive, real-time, and retrospective. Leveraging artificial intelligence within the CORTEX platform allowed Tracy’s team to prioritize their cases highlighting which patients were in possible status conflict and needed attention. Other benefits included write-off prevention, Level of Care consistency, case review efficiency improvements, increased team collaboration and transparency.

In Legacy Health’s case, a decline in total write-offs and a significant decline in UM-driven write-offs has occurred since this new technology was implemented. So, what advice does Neidetcher leave for her peers in the industry? “Leave no case undone. Align your teams. Streamline your efficiencies for success. And, always encourage collaboration with your payers to keep the patient at the center.”