Several factors keep utilization review from being fully appreciated: hospitals make status determinations in real-time, yet payers can deny a case weeks and months after discharge, making the true effectiveness of UR hard to gauge. Hospital leaders have difficulty connecting retrospective data to concurrent processes, bringing into question the compliance of each decision and the unintended revenue consequences.
A solution seems simple – end-to-end data – but the reality is that without a partnering the mix, data is often hard to find and disconnected. Without this data in hand, leaders cannot answer key questions: what is the ultimate result of staff decisions – are my real-time status determinations denied, downgraded, or written-off? What process changes can we address in real-time that stem from downstream issues or upstream processes?
Shortly after a newly-centralized UR function brought to light a heightened denial rate, Legacy Health sought visibility into the final outcomes of their status determinations through the partner they knew offered them a new approach: XSOLIS.
In March 2019, Legacy Health re-engineered its UR process with a data-driven foundation, XSOLIS’ CORTEX technology platform. CORTEX diverted attention toward high-risk cases: cases in the wrong status, conversion opportunities to inpatient, and two-midnight compliance risks. CORTEX also ensured Level of Care determinations were consistent among each UR nurse, while reporting from CORTEX were circulated among UR staff, attending physicians and others involved to further refine processes and improve staff performance. “Now I can log in each night and see which patients have had a review,” said Tracy Neidetcher, Manager of Utilization Management at Legacy Health. “And that’s not something we’ve had before. We are a strong team now.” Teams within Legacy Health increased their collaboration and transparency, coming together to find even more ways to tweak and refine their processes.
Additionally, Legacy Health engaged XSOLIS’ Denials Services (XDS) team to review and appeal their medical necessity denials backlog to ensure that payers were appropriate in their downstream denials. The XDS team detected abnormal denial behavior from several payers, with one consistently denying claims without physician signatures or specific reasons supporting the denials. The XDS team began to systematically appeal and push back on these cases, leading to a large behavior change across payers and drastically reducing administrative burden, filing fees, and multi-level appeals for Legacy Health.
In short, this multi-pronged approach had profound financial implications for Legacy Health: inaccurate decisions by Legacy Health staff (measured by the reduction in downgrades from Inpatient to Observation) were reduced by 75%. Relatedly, appropriate conversions have increased over 43% from March 2019 to July 2020, resulting in an eight figure positive impact to Legacy Health.
Another unexpected benefit was staff productivity: by preventing unnecessary rework, two FTEs were redeployed to aid in bed placement and Length of Stay initiatives (results at one hospital indicate 6% improvement). “My main reason for partnering with XSOLIS was efficiencies for my staff,” said Tracy. “But those efficiencies are equaled by the analytics and reporting I now have. We can now take action through data.”
Gaining the end-to-end view of each case has offered Legacy Health a chance to take control of their UM process. “If you don’t know what is happening [because of lack of data] …things are happening that you can fix,” said Tracy. “We just all have to communicate and to talk the same language. We have made a lot of progress and we will keep at it. Start by tackling one piece at a time.” By taking a proactive approach to utilization review, Legacy Health’s utilization management team ensures financial stability, regulatory compliance and staff productivity are top of class and truly effective for their organization.
The multi-pronged approach of
centralizing UR functions, utilizing CORTEX to divert attention to high-risk cases, and engaging with XSOLIS’ Denials Services had profound financial impact.
March 2019-July 2020