Transforming the Utilization Management and Physician Advisor Processes

Ensuring Patients Receive Essential Care

Martin Luther King Jr. Community Healthcare (MLKCH) stands out for its mission as a safety net hospital in Los Angeles, CA, catering to communities with limited access to healthcare professionals. Serving a significant number of Medi-Cal patients, navigating the complex payment model poses challenges. To guarantee comprehensive payment for services rendered and ensure patients receive necessary care, MLKCH sought support. Karen Taylor, Senior Director of Care Management, Social Work & Post-Acute Care Services, discovered Xsolis and recognized its potential to improve inpatient conversion rates when medically necessary, streamline team operations, ensure appropriate patient status upfront, and boost hospital revenue. Since the adoption of the Xsolis platform in October 2022, Karen hasn’t looked back, affirming, “Selecting Xsolis has been the most impactful decision during my tenure at MLKCH.”

Streamlining Processes with Xsolis Amidst Challenges 

Although Karen chose to implement the Xsolis platform, the onset of COVID-19 compelled her team to postpone the launch. Throughout the pandemic, the hospital grappled with patient surges and staffing shortages, exacerbating the strain on utilization management (UM) staff handling 60 to 80 observations daily. 
 
Once the Xsolis platform, CORTEX (now Dragonfly), was deployed, Karen’s team recognized the imperative to revamp their entire UM process, necessitating additional staffing. Insights gleaned from CORTEX facilitated departmental expansion by pinpointing areas for improvement. Moreover, Karen’s team developed concise UM workflows for the first time, enhancing staff training. Since embracing CORTEX, Karen’s team has achieved an 8.5% enhancement in review efficiency² compared to pre-platform implementation. The hospital has not only seen improved internal efficiencies including ensuring appropriate patient statusing but also experienced improvements in its processes with MLKCH’s payer partners. Karen stated, “The use of the Xsolis platform has strengthened our collaboration with payer partners. We can now analyze trends and patterns more effectively, enabling us to address issues promptly and with the necessary documentation.” 

Leveraging the Xsolis Care Level Score™ (CLS™) for Informed Care

Incorporating the Xsolis platform, MLKCH now utilizes the Care Level Score™ (CLS™) to guide patient level care decisions. Drawing from EMR data, the CLS provides a numerical representation likelihood of appropriate status for each patient, leveraging real-time predictive analytics and machine learning. Daily CLS utilization enables Karen’s team to prioritize cases effectively, expediting reviews and bolstering their productivity. While clinical decisions remain vital, the CLS offers a valuable starting point. Karen appreciates that, “the CLS dynamically updates as Xsolis’ artificial intelligence (AI) undergoes quarterly retraining.” 

“We serve a unique need in the community, providing care to underserved populations while regulatory requirements are constantly evolving. Xsolis helps us ensure appropriate reimbursement for the services provided and also puts us in a more defensible position to navigate future challenges. Their partnership has proven invaluable, as they consistently collaborate with us to meet our changing needs.”

– Karen Taylor
Senior Director of Care Management,
Social Work & Post-Acute Services

 

Innovating the Physician Advisor Workflow  

Dr. Sarah Kim commenced her role as a Physician Advisor at MLKCH concurrent with the Xsolis implementation, incorporating the Best in KLAS Xsolis Physician Advisor Services to supplement existing coverage. The Xsolis PA Team seamlessly supports Dr. Kim, intervening in cases as needed. A smooth implementation process, coupled with ongoing education sessions and collaborative rounds with the Xsolis PA team, enabled Dr. Kim to establish a protocol for concurrent denials, accelerating reimbursement capture. Dr. Kim highlights the contribution of this supplementary coverage to the hospital’s financial health, facilitating denial reversals. She emphasizes, “Xsolis is indispensable for efficient PA operations. It’s hard to imagine how other PAs do their jobs without this additional coverage.” 

Achieving Significant ROI and Operational Efficiency

MLKCH has leveraged the Xsolis platform not only to streamline processes and boost efficiency but also to achieve a substantial return on investment (ROI). From December 2022 to November 2023, MLKCH achieved a 2.7X ROI equivalent to $629K. “We serve a unique need in the community, providing care to underserved populations while regulatory requirements are constantly evolving,” said Karen. “Xsolis helps us ensure appropriate reimbursement for the services provided and also puts us in a more defensible position to navigate future challenges. Their partnership has proven invaluable, as they consistently collaborate with us to meet our changing needs.”

Schedule a consultation today to discover how Xsolis can revolutionize your organization’s UM and PA processes, accelerating reimbursement capture and driving favorable outcomes for your bottom line. 

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¹Legal Disclaimer: ROI projections are estimates based on similar system information and averages over the first 2 years of utilization. Such ROI projections do not guarantee future results. Actual ROI will vary based on various conditions and factors for each customer, including, but not limited to, client baseline information, best practice utilization of the products, etc.

²This metric is measured by reviews that are completed within 24 hours of the patient’s admission.