What Role Does Utilization Review and Quality Management Play in Managed Care

In this episode, we are joined by BESLER's Meliza Weiner to discuss the important issue of utilization management  and how it affects acquirement at hospitals.

Podcast (hfppodcast): Play in new window | Download

Subscribe Stitcher | RSS | More

Learn how to listen to The Hospital Finance Podcast® on your mobile device.

---

Highlights of this episode include:

• The different ways hospitals interpret and implement utilization management plans and processes.
• Reasons why it is prudent to take utilization management involved and aligned with a hospital's acquirement cycle.
• Ways that utilization management can help manage the cost and delivery of services at a infirmary.
• How a utilization direction department can facilitate and coordinate resources and services in a quality-conscious and cost-constructive manner.
• And more…

To view the transcript of this podcast episode, click Hither

For more insight from BESLER's experts on revenue bicycle, heed to our podcast episode "Strengthening the healthcare revenue wheel" which discusses how creating cross-functional initiatives can improve the revenue wheel.

---

The Importance of Utilization Direction in Healthcare

In the fast paced, ever-changing healthcare environment hospitals and health systems must be agile to ensure a quality-driven and financially stable performance. Between care complexities, endless reimbursement rules and regulation changes, utilization management in healthcare is paramount.

Regulatory Compliance

Regulatory agencies such as The Centers for Medicare and Medicaid Services (CMS) mandate for Medicare and Medicaid conditions of participation (Championship 42 CFR), The Social Security Act (Sect 1861 Regulation), and the Quality Improvement Organization (QIO) require that hospitals and health systems have an constructive utilization review plan in identify. Foundational elements of the Utilization Management department such as medical necessity, resource utilization, Length of Stay (LOS), denials and outcomes all affect reimbursement. Thus, information technology is prudent to take the Utilization Management department involved and aligned with the Revenue Wheel.

Payors and health plans set along many requirements in contracts which also affect reimbursement. Armed with the knowledge of payor and wellness program intricacies, the Utilization Management department tin can bridge the gap between quality care provisions and clinical medical necessity, intensity of services, coverage and reimbursement.

Having utilization management processes tied to fiscal policies ensures compliance from regulatory, quality and risk perspectives and provides a grade for hospital and health system operations. Different hospitals interpret and implement utilization management in different ways. Utilization direction could be a program, procedure or approach used for claims processing, resource utilization, deprival prevention, take chances direction and quality review.

Toll containment

The Utilization Management department can help with managing the cost and commitment of services.

The integration of the Utilization Management section and its processes within hospital operations can increase care efficiency and decrease revenue loss. For example, reviewing for medical necessity is one of the various utilization management processes. It involves a prospective (review of medical necessity for procedures and services before admission), concurrent (ongoing review of medical necessity for procedures and services during the stay) and retrospective (review afterward the discharge) reviews. This process solitary can significantly decrease the length of stay, help manage the appropriate apply of resources and services too as preventing denials thus protecting revenue.

Some of the various activities that Utilization Management may be responsible for include:

• Preadmission and admissions certification
• Prospective review
• Concurrent review
• Retrospective review
• Discharge planning review
• Case Management referrals for:
  • Nursing services and Social Piece of work services
  • Pharmacy and Respiratory services
  • Physical and Occupational Therapy services

Operational Efficiency

The Utilization Management department typically interacts with all, if non most, hospital operation services. By working with the healthcare team, Utilization Management department tin facilitate and coordinate resources and services in a quality-conscious and cost-effective manner.

Quality Department

The Utilization Management section should be involved in quality assessment (QA)/Quality Improvement (QI) activities such as evaluating patient care systems that includes standards, protocols, and documentation for efficiency.

Admissions, Registration and Scheduling

Appropriate communication and documentation of patient condition (inpatient, observation, outpatient) and discharge dispositions helps to ensure accurate coding, thus reducing denials and improving reimbursement potential.

Case Management

While Utilization Management departments are typically focused on price management and Case Management looks after continuum of care transitions, both departments have overlapping responsibilities and must work together. Both Utilization Management and Instance Management incorporate patient care navigation through the entire health intendance continuum from engagement to discharge/post discharge.

Revenue Cycle/Finance

With the impact utilization management has on the fiscal health of the hospital, information technology is important that collaboration exists between the Utilization Management department and the Acquirement Cycle/Finance department. Today's Acquirement Cycle teams accept admission to data and information technology that can assist Utilization Management to manage length of stay, appropriately classify resource, prevent denials and ensure accurate documentation for coding and appeals.

Originally, utilization management in healthcare started with a narrow focus. Now that Utilization Direction section activities increasingly influence reimbursement and affect acquirement, there is a move towards re-organizing or realigning Utilization Management to the finance function. Whether it exist a solid or dotted line to Finance, these teams must piece of work together to ensure the financial health of their institutions.

---

Transcript for "The Importance of Utilization Management in Healthcare":

Mike Passanante: Hi, this is Mike Passanante. And welcome back to the Hospital Finance Podcast®.

Today, we're going to be talking about the importance of utilization management in healthcare. And joining me to hash out this topic is Managing director and Clinical Review Nurse, Meliza Weiner, from the BESLER team.

Meliza, welcome dorsum to the show.

Meliza Weiner:  Hi, Mike! Thank you very much for inviting me.

Mike: And then Meliza, y'all and I take talked near this topic earlier. And when nosotros recall well-nigh how utilization management affects revenue at a infirmary, we kind of think about it in maybe 3 separate areas.

So, I thought in today's podcast, we could walk through those and go through some of your ideas and thoughts there.

So, the first being regulatory compliance. Why don't y'all tell u.s.a. about that?

Meliza Weiner:  Well, you know, it'south funny you mentioned that because no affair which organization you go through, they will always talk nearly regulatory compliance. And it actually makes sense.

So, regulatory agencies are there to make sure that we are doing what we're supposed to be doing for patients and our customers—and i of which is our lovely CMS.

So, the Centers for Medicare and Medicaid Services basically take a mandate. For any hospitals that participate with Medicare, they have to have a utilization management in identify. In fact, that's really stated in the rules, in championship 42. So, that needs to occur.

And for an arrangement to brand certain that they are in compliance with Medicare, they have to show them that they have in policy that they have a commission that looks at utilization direction.

And what utilization management really means is that you lot have to take a expect at what are you lot doing exactly for your clients? For healthcare organizations, these are your patients. Are you actually doing what y'all're supposed to be doing? Are you using the resource that you're supposed to exist doing?

And it makes sense. Information technology makes sense because the whole point of a healthcare organisation is to take intendance of patients. But you accept to brand certain that yous're doing the right thing for them—and rightfully so besides because healthcare organisation are also, let's face information technology and exist transparent, they're a business. So they need to have the financial stability to operate that way.

And and then, y'all demand some sort of a guideline. And that's where regulatory agencies come in.

You likewise have your Social Security Act that comes in place in there. And you take all the various payers, your quality improvement organizations too come into place for that.

Mike: Right. So, the 2d surface area that we've talked about is price containment which there's acquirement and at that place's costs, and of grade, utilization direction can help with the cost side too.

Meliza Weiner: Correct! So, utilization management, basically, what they practice is they expect at from the beginning to the cease. And so when it comes to cost containment, they tin increase the intendance efficiency, and they tin can also decrease the revenue loss.

So, a good example is reviewing basically for medical necessity. Now, medical necessity, you're going to hear this term used all the time. It's interpreted broadly. People tin can interpret it in unlike ways. But in essence, the focus of medical necessity is basically is the illness of that patient severe enough that yous also accept the intensity of the services severe enough that it warrants the care to be safely delivered in the hospital?

So, that being said, you lot take to make certain that you cover all those entities. The only manner to do that is y'all accept utilization direction in place. Nosotros're not sacrificing quality care. What they tend to look at is they look at criteria which is prove-based, information technology'due south clinical, scientific discipline or evidence-base. And they want to brand sure that do you need to be there when y'all're supposed to be in that location, and are you getting the right care.

So, a good example—and we phone call this a review. Yous accept a look—I always apply an case of if you lot're coming in let's merely say for i diagnosis. Allow's just say chest pain, you're coming in, and y'all're getting treated for chest pain. You have to take a look, okay, while you're in at that place are you lot going to become—while you're in here, let'southward go take a expect, and allow's do some other test. And since you're going to be doing this exam two months afterward, it has nothing to do with what you can.

So, we're not proverb non to practise the test. Is it the appropriate time to do the examination?

Then, that's one of those things that utilization management tin help and work with cost containment, keeping the revenue besides and not losing information technology. Because the one thing y'all don't want to do is not get your revenue. You accept to make sure that you get everything which you tin can get and have credit for it because y'all did the care.

Mike: Of class, collaboration leads to operational efficiency. And you and I have also talked about the appropriate place for utilization management departments inside an system. And we're seeing more than alignment within the revenue wheel, for instance. But not everyone does it that way.

So, talk to us about some of the collaboration that does occur between utilization management departments and other areas of the hospital and perhaps where you lot see the hereafter of that section landing.

Meliza Weiner:  Okay! So, allow's start from the beginning. I always start everything from the commencement.

So, when we look at utilization management, you have the front-end. Here's the front-end. You've got patients coming in. Before they come in the door, you can have utilization management take a look at "Are we ready for that patient to come up in? Do we have the necessary services to provide for that patient? Are the necessary payers enlightened? Did we go certification? Did we get all the papers in place?"

They take to piece of work with admissions. That's a section that, at the front line, they have to work with-work with admissions, work with registration because they are focused on what they're doing.

I'g not saying that they're siloed. A lot of people use the discussion siloed. They're not siloed; they're focused on what they're doing. Utilization management come in and assist support the admission section, the registration department saying, "This person is coming in. This is what they got approved with insurance. Practice we have all the paperwork in place? Practice we have all the information we need?" And then that's one.

With registration as well, they can help as far as coding. When the patient gets discharged, do nosotros have the correct disposition? They're the ones who's going to put that into the system, which is going to carry through to finance and billing. Then if they are putting in information that's not really truthful to do the picture of the patient, that could be a revenue loss.

A good example is if they're going to be discharged to a long-term facility, but information technology'southward beingness coded as a skilled nursing facility. That's a deviation of revenue. There's a departure of reimbursement correct there.

So, that's where utilization direction can come in. And it tin can say, "This patient was in for this condition. And they're getting discharged to a long-term facility. It should be coded that way."

So, it helps besides with coding. And it helps with reimbursement.

Another section that they work very well with is case direction. Nosotros just talked about discharge planning. And then, when discharge planning occurs, sometimes the focus is just the patient was here, permit'south just make sure the patient goes dwelling house, when are they supposed to go home.

Simply do they take the necessary services?

Utilization managers tin see that upfront. When they come in, they can actually see the patient, and they can say, "We're going to need maybe respiratory services to aid, peradventure nosotros need concrete therapy." They tin work in tandem with case management. And they can work on that at the first, so then when it's fourth dimension for discharge, they're non working on information technology at the back end, and then y'all increase the length of stay.

So, they tin can subtract the length of stay by working on discharge planning as soon as the patient comes in. We want to make certain that the patient gets discharged safely and accordingly; and and then, make sure that we do go our reimbursement for that care and services provided.

Quality department, the quality department focuses on the quality of intendance provided. They take improvement activities. Sometimes they call it quality improvement; sometimes, they call information technology quality assessment. They can piece of work with utilization management as far as standards, protocols, policy, as far equally processes involved. So that's another expanse that utilization management tin piece of work with that department.

Another department is revenue cycle. Revenue cycle in the finance department, they get all the information equally far as contracts with the payers, what'south going to be reimbursed, limitations and denials.

If they work with the utilization management upfront, they can mitigate those risks. Every bit far equally denials, they can work on making sure that everything that'southward a required function of the contract is documented. And so, it will affect coding, and it volition impact the reimbursement.

So, that alone helps with decreasing the revenue loss and making certain that they get the appropriate reimbursement.

Mike: Well, it'southward certainly a hot topic today. And information technology's certainly also a very of import area of the hospital and any operations. And certainly everyone needs to contribute to ensuring that revenue is optimized at each facility that you're capturing—every dollar that y'all've earned.

Meliza Weiner:  Correct, correct. I totally agree. I totally agree.

And correct now, there'south trends on where utilization management falls. Way back at the beginning, utilization direction started actually with the payers and have a very narrow focus. And now they are actually out at that place in the open, working with hospital operations.

And some have moved towards maybe working in tangent with revenue cycle, with finance. And to be frank, information technology doesn't thing whether utilization direction is a solid line or a dotted line to finance and revenue cycle. I retrieve what needs to be taken into business relationship is that utilization direction needs to be part of that team. They demand to work in tangent with the finance department.

The finance department have their knowledge of finances. Utilization management have their knowledge as far as payer requirements, guidelines, and clinical—which is the most of import thing, not to lose focus on the clinical attribute—that they can put it together and bridge that gap that usually occurs betwixt clinical and finance. They only need to work together because, nowadays, a stable healthcare organization needs to exist agile enough to piece of work with the regulatory agencies, contract changes, reimbursement rules and regulations, everybody.

But in a sense of what we always say, everybody seems to work together.

Mike: Right! Neat thoughts here today, Meliza. Thank yous and so much for joining me on the podcast.

Meliza Weiner:  Thank you very much.

---

woodshistrearret.blogspot.com

Source: https://www.besler.com/the-importance-of-utilization-management-in-healthcare-podcast/

Share this post