Implementing AI to Optimize the Observation Rate, Streamline UR Workflows, and Empower Clinical Teams
Inova Health recognized the need to take a more innovative approach to optimizing their utilization review (UR) and denial management processes while strengthening their payer partnerships. Inova sought to improve their observation rate, address inconsistent peer-to-peer attempt rates, and improve inefficiencies in their engagement with health plans. The health system identified Xsolis’ AI-driven platform, Dragonfly, as a promising solution, and Inova signed on for a six-month pilot starting in December 2024.
The partnership goals included:
- Optimizing the observation rate and capturing inpatient reimbursement by appropriately converting observation to inpatient
- Leveraging AI and reporting to better manage denials
- Using AI-driven insights to reduce unnecessary case reviews and optimize the internal Physician Advisor Team
- Utilizing Xsolis’ real-time notifications and prioritized work queues to identify and address potential missed inpatient opportunities
Reflecting on the implementation process, Michelle Greame, PA-C, MSHS, AVP, Revenue Integrity at Inova said, “We worked closely with clinical, IT and revenue cycle teams to ensure a smooth rollout—including provider training, workflow integration and performance tracking.” Michelle’s unique background as both a physician assistant and a consultant allow her to understand the clinical drivers behind care as well as the financial systems that support it. This dual perspective enables her to implement mid-revenue cycle solutions that are both operationally sound and clinically embraced, aligning clinical and revenue cycle goals to enable sustainable progress.
Data-Driven Insights: The Key to a Patient-Centric UR Process
Leveraging Xsolis’ Dragonfly AI-powered platform, Inova was able to drive efficiencies in the mid-revenue cycle. Dragonfly enables Inova’s UR Nurses to focus on complex, nuanced cases, ensuring patients receive the right care in the right setting, including converting appropriate cases from observation to inpatient status. Inova noted that the efficiencies gained through the Dragonfly platform have allowed their Physician Advisors more time and clinical discretion to advocate for patients who require an inpatient level of care, reducing unnecessary case reviews. Since implementing Dragonfly, Inova says it has experienced a substantial improvement in their review timeliness. On average, 80% of reviews are now completed within the first 24 hours.
Xsolis’ Care Level Score™ (CLS™) enables Inova’s UR Nurses and Physician Advisors to work at the top of their licenses and apply their clinical expertise. Powered by Xsolis’ real-time predictive analytics and machine learning, the CLS provides a numerical calculation that gauges the likelihood of appropriate patient status. Inova’s clinical staff no longer has to worry about “checking boxes” to categorize patients based on inflexible guidelines.
Michele Greame, PA-C, MSHS
AVP of Revenue Integrity
Inova Health System
“Xsolis offers a more dynamic and data-driven approach to determining medical necessity, reducing the reliance on rigid, criteria-based frameworks. By leveraging real-time insights, it helps streamline decision-making and allows clinicians to focus their time on more complex cases where their expertise is most impactful. Unlike traditional criteria, Xsolis’ CLS empowers Inova’s clinical staff to take a more patient-centered approach, leveraging data to support their clinical decision-making.”
From Operational Optimizations to Partnership Expansion
Not only is Dragonfly providing the Inova clinical team with the ability to better prioritize patients, but the reporting is also transforming the way they work. Real-time reporting gives Inova the insights and tools they need to consistently make improvements to their workflows and processes. This includes the ability to better understand and analyze health plan behavior, enabling Inova to proactively align with payer partners on patient status determinations, reducing avoidable denials and improving their ability to advocate for their patients.
Apart from the reporting insights, Inova’s UR Nurses and Physician Advisors can now have more robust, evidence-based discussions with their health plans. This has fundamentally changed how Inova collaborates with their payer partners to ensure timely authorizations and optimize communication and collaboration between the two parties.
Inova’s partnership with Xsolis has led to strategic optimizations across observation rate management, denial management, and unnecessary case reviews, coupled with enhanced efficiencies for Inova’s UR Nurses and Physician Advisors. Since December 2024, Inova has gained significant benefits and measurable impact through Xsolis’ solutions.
Michelle and her team are looking forward to expanding on the benefits experienced by partnering with Xsolis. Going forward, Inova is exploring connecting with health plans through Dragonfly to further improve communication and collaboration between the two parties. Additionally, Inova is excited to leverage Xsolis’ innovative GenAI offerings and Best in KLAS Physician Advisor Services to drive even greater enhancements to their clinical and operational performance.
To discover how you can use AI-driven insights to optimize mid-revenue cycle processes, contact Xsolis today.
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