Health System Makes Utilization Review Paperless, More Efficient
By Melinda Young
As health systems update and revamp their electronic health records, they might want to consider adding a case management module.
An electronic health record that includes an acute case management module with robotic process automation can create seamless efficiency, says Patricia Resnik, MJ, FACHE, CPHQ, vice president, care management at ChristianaCare in Wilmington, DE.
“In the past, case managers would have to go into the record and review it themselves by reading the medical record to determine whether it was an observation or inpatient level of care,” Resnik says. “Now, they can validate through an automated review.”
The health system’s case management team is trained in utilization management, and most of the reviews are handled by the utilization management team. The electronic system runs a review and presents it to the nurse, who finalizes the report, she adds.
“The determination of inpatient status is always the physician’s decision,” Resnik says. “The auto-review runs [its process], and if documentation doesn’t support that decision, then it brings this to the nurse’s attention.”
Nurses initiate a discussion with physicians about the appropriate level of care for the patient. “If the automated review comes back and says [conditions are not] met, nurses see that in their work list, and can go in and evaluate that review,” Resnik says. “It gives them the opportunity to have a discussion with the physician, and tell them the documentation is not supporting an inpatient admission.”
The physician can confirm that an inpatient admission is necessary, and the nurse can forward the doctor’s information to a physician advisor at the hospital level. The physician and advisor can discuss the case and the appropriate level of care. “Ultimately, it’s the physician’s medical judgment,” Resnik says.
If the physician believes the inpatient admission is needed, then the physician advisor can talk with the payer’s medical director about the case. “They will have a discussion with the payer about how the physician advisor is supporting the attending physician’s decision to admit,” Resnik says. “Our physician advisors have a very high overturn rate, meaning they get that denial overturned at first peer-to-peer discussion 65% to 70% [of the time].”
Robotic process automation brings information to staff earlier in the patient’s admission. “When we see it is partly meeting or not meeting [conditions], then we know to expect the payer to deny the claim, and we can have a discussion with the attending physician sooner,” Resnik says.
Another utilization review management efficiency is the health system’s concurrent denial management process, led by the utilization management team with physician advisors.
“If we get notification from a payer that they are denying a claim, then our physician advisors do a level of review to get this resolved before the patient is discharged,” Resnik explains. “If the denial remains, management of the denial will occur after discharge through the patient financial services team.”
That team has access to all dates, documentation, and information about the case and denial, and will continue to manage the denial.
Utilization management has become so efficient that case managers can take on additional work functions because of the time saved by the auto-review, Resnik says. For example, case managers now have more time to be proactive. They have more time to evaluate patients’ medical records, and work with physicians to ensure the severity of patients’ illnesses are well documented.
“When we gained efficiencies in the robotic process, we decided we didn’t need two nurses looking at a particular case,” Resnik says.
It also reduces the number of people who have to reach out to the physician, Resnick says. “We can expand the number of cases that we’re able to see in the day because we don’t have two nurses on the same case.”
Utilization management with robotic process automation has made it possible for the health system to meet several overall goals. “We are always curious, and continuously look for ways to innovate our work well,” Resnik notes. “When the opportunity came along to co-develop this automated system, we knew this would help us be more efficient and effective, and use our resources wisely.”
The automation supports the health system’s goals for continuous learning and change.
As health systems update and revamp their electronic health records, they might want to consider adding a case management module. An electronic health record that includes an acute case management module with robotic process automation can create seamless efficiency.
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