Real-Time Access to Members' Clinical Information, Automated Authorizations Through Analytics

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.

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See How XSOLIS Bridges the Gap Between Providers and Payers

Your Journey Toward Transformation

Automate Case Reviews

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.

  • Up to 40% of Inpatient cases can be automated with 99% accuracy
  • Reduce cases touches by 18 – 30%
  • Significant reduction in administrative work and appeals burden
  • Reduce provider friction by using benchmarks agreed to upfront

Real-Time Access

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.

  • Removes the need for multiple emails and faxes
  • Get access to data as it added to the hospital’s EMR
  • Provider and payer see the same information
  • No more information overload from overzealous partners

Status Determinations Done Right

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.

  • Accurate status determinations up front
  • Have a normalized view of clinical information for all cases
  • All medical necessity clinical indicators are highlighted
  • Analytics gives guidance on borderline cases

Reduce Friction

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.

  • Agreeing to metrics upfront reduces frustrations
  • Create better user experience for provider partners
  • Single source of truth for medical necessity
  • Turn case approvals around faster

Proven Time Savings 

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.

    • 10-15 minutes savings per case review based on national payer analysis 
    • More accurate interpretations since fewer data to wade through
    • Trending acuity graphs help focus review on crucial fluctuation points
    • Gives a consistent experience for end-users
Schedule Demo

Learn how Humana is driving change with their partners

Healthcare can’t remain a zero-sum game. XSOLIS CEO Joan Butters recently joined Humana SVP George Renaudin for an in-depth discussion on the state of today’s payer-provider relationships.

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.

Beckers Webinar - Data-Driven Network