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EvidenceCare had the privilege to host an incredible virtual event on Disruptive Trends in Utilization Management as part of our ongoing Fireside Chat series.

The event featured panelists Catherine Pesek, DO, MBA, CHCQM-PHYADV, Physician Advisor at Lakeland Regional Health, and Andrea Ortman, VP of Inpatient Care Management and Post Acute Care at Geisinger. We were joined by utilization management leaders across top health systems (such as Allina Health, Ardent Health, AU Health, InovaLCMC, UF Health, and Wellstar) who offered various perspectives on current disruptive trends in utilization management.

The following is a summary of the topics discussed.

Solving the Clinical Shortage with Technology & Process

As a shortage of nurses, doctors, and even administrative hospital staff grew to record levels during the pandemic, many top health systems realized that trying to get “more bodies” wasn’t a sustainable model. Even if you’re able to hire more clinicians, they’re expensive and don’t often address the root problems in utilization management. It’s the processes around clinicians that matter more, and that’s where technology can drastically improve the status quo.

Utilization management teams work with high value cases that if not handled and prioritized properly, can leave a ton of money on the table for hospitals.

As one participant said, “It takes a lot of preparation and planning to do it efficiently. We looked at technology and process to help guide us through our day-to-day work.”

One of the most insightful observations among the group was how easy it is to put self-imposed guidelines on your UM process that aren’t regulatory.

Medicare Conditions of Participation and discharge planning rules are used to guide hospital policy but taking the time to truly understand what’s required versus what’s simply causing unnecessary bottlenecks in your internal processes is crucial.

From a technology standpoint, one health system modified EHR work queues to consistently identify what work had to be done. For example, they eliminated Medicare Inpatient cases from being touched repeatedly by clinicians and utilize bots that can complete rote functions like Notice of Admission or Notice of Discharge.

From a process standpoint, one health system had the Rev Cycle and UM teams work heavily with legal teams to establish a nursing protocol where nurses can queue an order (e.g., conversion order) without going back and forth with doctors. These orders must be co-signed by a physician prior to discharge, so it does carry some risk, but it has significantly reduced UR work effort.

In the absence of “queueing orders,” others suggested the importance of combining assignments for UR functions. The UR nurse’s role may be assigned to rounding on a particular floor, focused on peer-to-peer and immediate appeals, serving as a “swing nurse” who also works with the physician advisor on denials, which helps create a seamless program to handle cases.

There was overall agreement that implementing technology solutions that make evidence-based criteria like MCG and Interqual easily accessible – even if difficult to implement internally – drastically improved efficiency and better utilized limited clinical resources.

Getting in the Weeds of Contracts

Since we mentioned legal teams, contracting was another big topic of discussion.

Payers are trying to define the readmission review process terms, and it’s a difficult task with diseases that progress such as heart failure or the issue of non-compliant patients.

Leverage your hospital association and review the terms that payers are using to hold you accountable to short stays. Working together as a combined voice creates impact and can change payer policy.

Dr. Pesek talked about one of her favorite parts of her role, which is being the physician advisor voice in the contracting room to ask questions like, “What’s a reasonable readmission timeline?” or “Does the Payer have resources to help us decrease that rate?”

“If all of us have the goal of keeping the patient out of the costly hospital bed, then we all need to work together, especially in areas where we have outpatient clinics busting at the seams.”

When a physician advisor understands contracting and participates in the Joint Operating Committee (JOC), over time they’re able to learn the nuances of Payer agreements and earn a voice to show example cases and trends that may inform a change.

This is an important part of the appeals process, but Dr. Pesek encourages not bothering with cases that don’t have merit, but to go through the full process with Medical Directors for cases which you strongly believe have merit. It’s a learning opportunity for everyone involved. A heart failure patient may have a different reason for their “disease state” such as a valvular issue versus too many fluids.

Related to discharge planning, another participant made the point that there are certain legal and contractual requirements on how long a hospital must wait to receive a determination. Often patients get stuck in a holding pattern, but if you know the required timelines, it may help you move them to the next status if the Payer is delayed in making a decision.

Keep track of the request date and micromanage this process. Hold the payer accountable for their member.

“When you have a volume of cases that you’re not receiving those responses back, you can work with your health system’s contracting department, and you can also reach out to your accrediting bodies and share with them that you’re not receiving those responses.”

A few last items of advice on this topic were to 1) find a contact at OIG, 2) find the person/department in your hospital who handles government relations, and 3) don’t be afraid to talk to the accrediting bodies over health plans.

Look for Unconventional Ways to Solve Conventional Problems

It was both comforting and alarming to hear UM leaders at the event share much of the same issues, even without any prior discussion. This revealed the numerous conventional problems all utilization management departments face. The encouraging part was that these leaders have found unconventional ways to solve conventional problems.

Here are a couple examples:

One participant set up a process for Medicare Advantage payers to utilize the Appointment of Representative Form (AOR) to allow them to appeal on behalf of the patient. Payers must post and report on what the determinations are, so if CMS starts to see AOR denials are heavily upheld, it raises a flag to CMS. By having a good process around patient admission and ensuring it’s done prior to discharge, the team can meet concurrent denials with concurrent appeals, which have resulted in a high overturn rate.

For bundled programs, another participant shared a shift to case managers optimizing patients prior to coming in for procedures like Total Knee Arthroplasty and Total Hip Arthroplasty.

“Case management got involved early to do preoperative assessments to determine what post-acute care was needed. There were very few patients who actually needed skilled nursing, whereas prior, it was almost anticipated that if you underwent either of those procedures, you were going to go to skilled nursing.”

Using remote patient monitoring and telemedicine bundles helps keep patients at home and prevent readmissions.

Others chimed in on the importance of ongoing physician education as regular practice to ensure changing definitions and guidelines are communicated effectively. It’s the long, hard work of education that reaps long-term benefits like getting better medical documentation and shortening length of stay.

Ongoing Trends in Utilization Management

We hope these insights from our conversation were helpful as you navigate ongoing trends in utilization management at your health system. If you’d like to join one of our future Fireside Chat events or learn more about how EvidenceCare’s products can help your utilization management team, please contact us here.

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