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XSOLIS’ Utilization Review platform, CORTEX®, acts as a shared framework for case review and authorization between payer and provider - CORTEX gives payer staff a real-time view of each case escalated to them by the provider, expediting the review process while reducing redundancy - all without the need for digging through the electronic medical record.
Payer and provider can also jointly set an analytics threshold for automating inpatient determinations based on true clinical merit, a process we call Precision UM.
CORTEX uses XSOLIS’ analytics to give guidance on the appropriate status of a member. As the analytics are more confident of the appropriateness of Inpatient status, the analytics scores go higher. When analytics are above a specific threshold, payers and providers can agree to automate approval, significantly reducing case touches and payer-provider back-and-forth. This automation is referred to as Precision UM.
Typically, payers must wait on updates and faxes from providers or have to wade through pages of EMR data to find the clinical information needed. CORTEX gives payers real-time access to member’s medical information curated to remove extraneous data found in EMRs. CORTEX only presents the relevant information required for status determination.
CORTEX uses XSOLIS’ Analytics to predict appropriate status based on that member’s labs, vitals, medical history, orders, meds, and procedures. With CORTEX, both payer and provider are on the same page for each member's status - same analytics, same technology, correct decisions.
When the payer and the provider are using the same tool, there is a reduction in misunderstanding and disagreement. By looking at the same information, it is easier to come to the same conclusion.
By payers having access to clinical information, there is less back-and-forth between the payer and the provider. CORTEX extracts the relevant clinical data and removes the superfluous details making it easier to for reviewers to home in on critical data.
Their conversation covers three arcs: zooming out to the status quo and why it can’t stand; zooming in to what XSOLIS and Humana are doing to transform the discipline of utilization management; zooming back out to how the industry can adopt this forward momentum.