EXECUTIVE SUMMARY

Some larger organizations are creating a centralized utilization review (UR) process. Taking the UR functions away from the unit-based case managers can result in more time at the bedside, but there are factors to weigh before investing in a centralized process.

• Develop a solid, transparent communication plan for the whole team to minimize the potential for duplicate duties and extra work.

• Consider how electronic methods could make this approach possible — but don’t forget to include the information security department to protect patient information.

• Continue to meet regularly with stakeholders to gauge what fell through cracks, the number of denials, and what can be improved.


With utilization review (UR) requirements and guidelines becoming more and more onerous, many larger organizations are creating a centralized UR process. That means that when a new patient is registered in the ED, an offsite case manager can be alerted to the new patient, see all documentation necessary to determine whether the medical record supports the patient’s status, and work with the physician on the phone or the ED case manager while the decision is being made to admit or begin observation services.

Because the offsite reviewers are working from a remote location, they do not need to see patients for this step in the utilization process.

“What we’re seeing are a number of organizations centralizing and combining their utilization review. Many are in hospital systems that are continuing to combine and consolidate. It is occurring at large healthcare systems, and I know of several of them,” says Brian Pisarsky, RN, MHA, ACM, a director at KPMG Healthcare Solutions.

Pisarsky speaks of a 13-hospital system in the Midwest that implemented offsite UR after experiencing a significant increase in denials and multiple issues with payers.

“In order to solve this, instead of having 13 different processes, now they have one,” he says.

While this sounds like an effective solution that comes with obvious benefits, it’s also a system that requires streamlined processes, transparent policies, and an eye toward minimizing any potential risks.

On the one hand, taking the UR functions away from the unit-based case managers frees them up to spend more time at the bedside. On the other hand, it could lead to breakdowns in communication, among other issues, says Beverly Cunningham, MS, RN, ACM, partner and consultant at Case Management Concepts.

“We have never seen a model where there hasn’t been a silo mentality and a decrease in the sense of urgency when a separate UR function is incorporated,” Cunningham says. “The vast majority of these are off site, and this is difficult for communication with staff, physician advisors, the ED, and patients.”

Benefits to Offsite Utilization Review

The following are a few pros to consider, with a glimpse into how others are implementing such systems in their own organizations.

Pro 1: Maintaining a common process.

If two hospital systems come together and there are now six hospitals, that means six different UR departments must keep up with CMS rules and all rules for every payer. But if they centralize all utilization review, they have a common electronic medical record to review every single patient.

“Now you’re bringing that into one source and every patient is being reviewed as they need to be. It really brings those folks together who know the rules. It becomes a common process. That’s a big move,” says Pisarsky.

Pro 2: Understanding denials.

A centralized, consistent process can better use resources, can ensure a better understanding of what is denied up front, and streamline which payers are giving hospitals the biggest issue.

“In my opinion, if utilization review is a centralized process, then the UR specialist should be the first person who is looking ahead to see what’s needed to get approval, and they should contact the physician to get what is needed to support the level of care,” says Vivian Campagna, MSN, RN-BC, CCM, chief industry relations officer for the Commission for Case Manager Certification.

Then, the UR specialist should contact the case manager to inform him or her about a potential denial because the patient isn’t meeting criteria for admission, she cautions.

“At that time, the case manager can contact the physician to discuss the patient’s acuity or whether they should be moved to another level of care. That’s how it should happen — before the denial, not afterward,” says Campagna.

Pro 3: Reducing readmission rates.

When UR is separate from case management, it allows case managers the time and opportunity to perform the roles and responsibilities they do best, like care coordination. If hospitals task case managers with daily insurance utilization reviews, it may preclude them from meeting with patients, working with physicians when they come in, participating in team huddles, coordinating care, and ensuring the patient has the resources, information, and education to move toward goals and reasonably advance toward discharge.

That’s the work that will help avoid a readmission, according to Campagna.

“I think it’s good to have a clinician — for example, a nurse — who becomes a utilization review specialist — a person who knows the nuances of the reimbursement system and specializes in it — rather than the case manager doing utilization review. As a specialist, they are familiar with the various insurance and Medicare contracts and carveouts, as well as what’s required to justify the patient’s admission and hospital stay,” she says.

A specialist will provide the pertinent information to document the acuity of the patient more efficiently. When case managers perform UR, it typically is an administrative task in addition to case management duties.

Campagna points out that because it’s not their core work, there is a tendency to offer too much information from the medical record, which can open opportunity for a denial.

“It’s in the hospital’s best interest to place the individual who best understands the CMS and managed care guidelines and the individual contracts involved so they can structure the information needed in the most appropriate way,” she says.

Things to Consider With Offsite UR

The following are a few possible cons of offsite UR, and ways an organization can work to prevent these problems.

Con 1: Lack of communication.

The offsite utilization management staff rely on transparency and continually updated data while communicating from an entirely different location than physicians, case managers, social workers, clinical leadership, and other staff.

Although offsite UR teams can email daily reports to the hospital-based case managers, there should be effective communication plans in place from the start, according to Pisarsky. Take into account that if the organization views the role of utilization management as an isolated set of tasks, the role could become separated from the other roles of the case manager.

After all, utilization review should drive the discharge planning across the continuum of care.

“In other words, if I’m the case manager on the floor, I know the patient is moving along and moving away from still needing to be in the hospital. One possible problem with offsite UR is lack of communication. For example, when you’re depending on the case manager on unit to be informed by UR staff that a denial has occurred, or this patient is running out of criteria to be here,” he says.

Remember that investing in a centralized UR process without a great communication plan between all stakeholders is essentially creating duplicate duties, potential for poor communication, and extra work.

If organizations are looking to implement this and have distributed team members, they should bring all stakeholders in to ensure they’re mapping this process every time and for every patient. For example, when criteria changes, are there monthly in-office trainings and continual interrater peer reviews to verify accurate criteria and policy/procedure application?

“As organizations continue to implement processes for centralized utilization review, there are many ways they improve the process. Initially their key stakeholders should be meeting weekly, then move to monthly meetings, but I don’t see where this key stakeholder team will ever go away,” says Pisarsky.

“Stakeholders need to make sure they’re reviewing during these meetings current opportunities for improvement and what fell through cracks,” he adds. “They must be reviewing denials, and they must always ask ‘What didn’t we do appropriately and what can we do better next time?’ to find remedies.”

Another dynamic is figuring out — and effectively communicating — staffing ratios for centralized vs. decentralized processes. One example is having 150 case managers across a hospital system performing UR that now wants to centralize, and working out who works on holidays and weekends.

But it’s impossible to define a specific staffing ratio, according to Campagna, because it depends on the type of patient on the unit and even the type of patient the hospital sees. For example, a safety net hospital may see more patients who require more services from a case manager, while a hospital that serves more managed care patients typically requires case management to interact with fewer complex patients, she says.

Because it would be tough to determine how long each clinical review will take, it would become a matter of performing the process for some time, meeting regularly for review, and then collecting information to create benchmarks, Campagna adds.

A good first step in this process is to form a committee and meet at least four to six weeks before making this change. Make sure to map all the necessary processes. Pisarsky offers these points to consider:

• talk about best practices;

• work out logistics (e.g., “Do I take two folks from every campus, or will UR staff work from home?”);

• determine metrics/ratios;

• implement logistics (e.g., Where will staff work? What are the roles of the different individuals? How do we notify if patient is getting denial? How do we notify doctors?);

• implement communications methods (e.g., What new software, tools, or systems would need to be implemented?)

Con 2: Who’s contacting the doctor?

With an offsite utilization review in place, who is talking to the physician? Does the remote UR staff call the onsite case manager to talk to physician, or do they call the physician directly?

Consider a scenario where the UR team receives a denial, necessitating a peer-to-peer discussion between the doctors. Because the UR staff knows what information is needed to demonstrate acuity, they should call the physician directly and ask for appropriate documentation, according to Campagna.

Also critical is developing policies and procedures for all criteria, including notifying the insurance company, denials, and the processes for a referral to a physician assistant.

“When the patient is looking closer to meeting discharge criteria, what would need to happen in talking to the physician is he or she may say ‘I think this patient needs one more day and here’s why.’ So we’d want the physician with the insurance company to have a peer-to-peer conversation with the physician who is seeing the patient,” Pisarsky says.

He points out that the case manager on the floor knows the physician much better than a UR person who is working remotely.

“That’s where I see a major misstep with UR being done remotely — who talks to the doctor and the patient?” he says.

One way to avoid this pitfall is to consider the use of video meetings or discussions with the offsite UR team.

“There are organizations that have computers on wheels and have the patient talk to physicians over that system; there are a multitude of electronic methods that make this approach possible,” he says.

Con 3: Data security policies and cybersecurity threats.

Remote electronic safety is another potential concern. Case managers who work from a home office with online access to patients’ sensitive medical records are tasked with many responsibilities, including working with physicians to determine the patient’s status and level of care on admission, and determining whether the patient meets admission criteria. But what about protecting the privacy of patients’ records?

“One of the imperatives is have your information security as part of the key stakeholder team. There are organizations in the western U.S. where every single one of their reviews is handled remotely; they just need a laptop or PC at home to connect in and parameters around reviews, such as how many per day, and a telephonic or secure fax or email notification process,” says Pisarsky.

The very real risks of cybersecurity attacks and data breaches should be understood among all team members in a distributed, offsite UR team. Include the information security department to figure out which security measures need to be included and make sure everyone on the team is following the same protocols.

Evolution in the Role of Case Manager

This division of labor between the centralized UR specialist and the case manager also could be signaling something of an evolution in the role of the case manager.

Utilization review used to send the information to the insurance company and then wait for them to call back. Now, it is a 16- to 24-hour-a-day process at many institutions.

“I think hospital administration needs to recognize the fact that there are many things that add value and better merit the case manager’s attention other than utilization review. Especially in today’s EHR environment, UR is a function that can be easily done outside the scope of the case manager’s job description,” says Campagna.

“Professional case managers should be focused on care coordination throughout the acute episode of care; managing the patient with the team to do the assessment, creating the plan of care, overseeing its timely and efficient implementation and, when it’s time, moving the patient to the appropriate level of care with the best education and information possible to prevent an avoidable readmission,” she adds.

From a leadership standpoint, she adds that the role and the value of the case manager could get diluted when tasks such as UR are added to the workload. Because of time and workload constraints, this can make them less effective to do the important tasks of case management.