Adventist West’s success through redesigning and automating UM

Case study: Adventist Health's success through redesigning and automating utilization management.

I'm Rose Patton of Becker's Healthcare and I'd like to thank you all for joining us today.

Before we meet today's speaker, I will go over some quick housekeeping details.

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With that, I'm pleased to welcome today's speaker, Regina Berman.

Regina is an integrative care management and ACO executive for Adventist Health.

Regina is responsible for the clinical components of the revenue cycle and value-based care initiatives

and is skilled in designing whole system change, program integration, and analytic platforms for clinical and claims-based data integration.

Regina, thank you so much for being here today. I'll now turn the floor over to you to kick things off.

Thank you very much. Just checking that everyone can hear me okay. Thanks for the introduction, Rez.

I'd like to just begin by telling you a little bit about Adventist Health.

If you're not familiar with us, we are a primarily West Coast Health System, but also have multiple facilities in Oregon, California, and Hawaii.

Generally, a little bit of by the numbers, we have over 400 provider practices, 

28 hospitals, six ACOs, multiple SNFs, integrated CINs, Knox Keene Health Plan, IPAs,

and in this past year have provided over a billion, that's a 1B, donation to community services.

So it's a faith-based organization that has a deep commitment to those we serve,

and we're helping and hoping to continue to redesign so that we can do that more fully going forward.

We thought we would cover some objectives today in this story and in general, summarize the benefits and

the practices of implementing a centralized exception based utilization management program.

And we'll show you that there has been a journey to get us to the point where we are today and 

some of those key learnings that went along with it to construct the programs and the workflows to optimize defensible.

automated medical necessity reviews, demonstrate how to strengthen the relationships with payers, 

and then the journey in and of itself. And of course, to celebrate all that has been accomplished and

we hope you'll join us in celebrating some of those results. I have a polling question.

There are four throughout the deck. And the first one is, do you, the participants or those you work with, 

have a centralized utilization management program? meaning case management and utilization functions are separate.

if you wouldn't mind just selecting A or B. And I think we just have to pause a little bit to see what the results are.

Some of our results are in and 72% say yes, that's wonderful. That's actually higher than I expected and I'm happy to hear it.

I think it's reflective of the world we're living in and the automations that exist and

actually the specificity of the criteria that we all need to know and work with every day.

So as this journey continued. or began, we really looked at what our current state reality was versus the desired vision that we wanted.

The, you know, looking at how we were using basically an old deming phrase, people, methods, materials, and machines

How were we using automation and technology? What was the subject matter expertise of those we were relying on?

And then how did the teams communicate and align across the organization.

So here's what I felt I experienced when I first got involved.

I became involved in the integrated care management work fourth quarter of 21 and

while the vision was a very strong and possible vision the reality was quite different.

So the picture we had was, I'll show you in just a second, a little bit more fragmented than we had hoped.

And it was driving very, very high rates of denials.

The decision to go to a centralized model occurred actually prior. to COVID. So you can see that in about 2019 the decision was made to do that.

It predated me. But what we found was that even though there was new technology that was purchased and installed, we were not maximizing its use.

So we really became much more deliberately involved in how we organize the teams and the workflows in order to reverse the negative trend we were seeing.

Now remember that was in the heels of COVID. Everyone was in recovery mode. The denials had escalated and the teams were just fragmented.

And as you know, they were workforce struggles as well. So this is the sort of the pre.

The pre change model where we had all of the functions and components of you are discharge planning case management care coordination,

but they were working in swim lanes or silos.

It was the perfect storm, so we had everything from a tools standpoint, but we were not optimizing them, we were not using them very effectively.

and the growing financial pressure was becoming really quite extraordinary. So the first step was a restructure leadership-wise.

I had previously been assisting Adventists with the value-based care and we set up six ACOs,

and I was asked to create something called a Care Progression Model, which is a conversation for another day,

but it was really this concept of integrated care management across the continuum, including inpatient, ambulatory, and

beyond, looking through the lens of the patient. So this is, let's say, an early part of the journey to accomplish that entire model.

So as we took a closer look, we found that the, I think of the UM team as the mid-rep cycle team, and I think many of you do.

So as we started looking at that, there just seemed to be a lot of stops and starts.

Okay, so those of you who are familiar, you have the front end, which is registration notification.

verification of insurance, and then the CMRC, as we call it, which is the Centralized Care Management Resource Center.

They then go from clinical authorization, clinical review processes, and then clinical denials.

And the clinical denials was a change, which I'll show you in a little bit. And then of course you go to billing coding and etc.

So we are that middle piece, and what we and were not working as intended and was really leading to a lot of rework.

excessive rework and limited visibility or tracking on any trends or patterns. It was basically a case at a time.

So we said, what's happening? I will show you some data about the auto-review process that we installed.

And what we found is that we were minimally achieving benefit from it. And the question was, why? 

And so one of our colleagues, Ian, who you will hear from later, was representing Change Health at the time, now, often, 

and we got on a call together and I said, what is happening here and what do we need to do to make it better?

And the answer was a single admission diagnosis

So I want you to remember that as we go through the slides because that is a foundational piece of the success

and the efficiencies that we've accomplished.

Basically, the idea of any of you are lean people, the idea we can do better or let's have a Kaizen event came up.

We are not a lean shop, but we do take the tools out of the tool kit that are needed at the time.

We basically did get a cross-functional team together, sat in a room for a week.

In a hotel, we wanted neutral territory and involved. You can see a cross-functional team.

And we said, let's go see. And we had each group go through their workflows, their assumptions, their decision-making, 

their reporting, their visibility. And what was amazing out of that body of work is in the room, we also had an architect and

some of our EHR support personnel, and we were able to make changes in that room without going through protracted processes.

It was a very rapid cycle change environment. We found some logic issues, we found some other issues that were impediments to workflows,

and there were 14 items that we identified as quick wins, and we're actually able to leave the room with those in place.

There were a total of 44 items that were identified and the rest of it went on as you would with any typical improvement plan

where we had teams, you know, commissioned to work on them and come back in with weekly reports.

But what the outcome of that was is we really went from this siloed model more to a team sport.

And people were celebrating, people were relieved. They felt that it was an equal representation of needs and

understanding of each other's workflows. And I think it really set the pace a much more collaborative environment.

There were four major things that we really understood had to happen. One was optimizing existing technology, and

as I mentioned, we did some of that right in the room. Think about that if you're doing some change modeling that involves your EHR,

or your RebCycle tools. Of course, we needed to look at staff productivity and the things that were barriers to that productivity.

focus on denial prevention instead of appeal processes, because the rate of denial was unsustainable.

And then, of course, to change the culture and become a we as opposed to an us and them. And I do think that was accomplished.

So let's pause now for a second polling question. If your UM function Is staff separate, is your UM function staff separately or

integrated with your onsite So an integrated separate or other if it's other and you'd like to answer put an answer in the chat

so we can see what the other might be. It would be helpful. and we'll pause for a little bit.

Okay, okay, so this is interesting. The first question we talked about a centralized model, and yet we do have them staffed separately.

So those two are interesting to think of in combination with each other, and hopefully in the Q&A we can tease out some of the thinking around that

Okay, so here's a little bit of a journey map, and you can see I won't read all of the pieces and parts,

but The major change that initiated all of this work was the decision, I report directly to the system CMO,

and he made a decision to move case management in two ways. One was from the local markets to the shared services and

the second was to have them report to the medical officers as opposed to the nursing leaders, which is... pretty typical.

Usually it's the nurse leader or the PCE where case management resides.

And one of the reasons for that is because we found that the other duties as assigned component

became the basis of the precise work that needed to be done

He also, as a new system CMO, wanted to hold the medical offices accountable for the outcomes.

and make sure there was alignment between case management and medical staff.

So that was a pivotal decision, which you'll see when we get to the discussion about a single admission diagnosis really accelerated

the ability to make that change. Okay. So then, you know, of course, I was hired to sort of lead the charge.

When I started to share my initial assessment with a cross-functional senior leader team,

I think I was about two minutes in and they said, just fix it. Because there was so many items, they just said, just go fix it.

So I'd given free rein to do what I had to do. And I think we responsibly got the teams together to work in that spirit.

So anyway, we advanced to look at things, which included narrowing the scope of what we were asking the teams to do

And in that time, length of stay. was very high. So we wanted the inpatient teams to focus on length of stay and denial prevention and

then which would also help to eliminate some of the rework on the back end. Okay.

And then we wanted the rev cycle teams to work more collaboratively with solutions on how they shared information among and between each other.

So why not we'll go forward from there. So the new model or the refined model, if you'll call it,

is a more integrated model where we actually have each of the staff teams identified with their specific functions and

then really try to make sure they were focusing on those functions. So the RN case manager is always going to be responsible,

regulatorily and otherwise, for doing a very good screening assessment. and initial, you know, early discharge planning

and then facilitation with the providers. and making sure the daily activities are going as intended with a plan in place and

to get off track there. You know, the complex transition planning, the discharge planning, financial, psychosocial issues, our social works realm,

and then for the core utilization team, which now, by the way, since COVID and post-COVID do work remotely.

Prior to that, they were on site, but they're now remotely. They're really responsible for doing the initial authorizations,

the initial review for appropriate level of care and continued stay reviews. Then of course, we have built out a clinical denial and appeal process.

That was not a separate component. One of the recognitions we had looking at this information is that the inpatient teams,

because I have responsibility for both, I was really trying to understand the needs and barriers on both sides.

This is data from a tool we use called EnzoCare. And EnzoCare is something we use to request post-acute placement for patients, primarily SNF.

In this period of time, there were 300,000, but there were 300,000 requests for SNF placement across the system.

The response rate was 96%, but it was mostly no. So we really had a problem with post-acutes.

And so when you talk about length of stay, when you talk about denials, this was driving partial denials, a lot of avoidable days, and other things.

So we really found the need to partner with the payers differently, to leverage their. complex care management teams and

to challenge their network adequacy. So I wanted to call that out because a lot of this, solving those problems cannot happen through utilization review.

Those have to happen through partnership with the payers and through your approach to post-acute management

But the other really notable change, and you'll see one here, is that one patient required 1% of the patients required 3,000 requests for placement.

So this is an extraordinary time consumption and it was just not a pretty picture.

The conclusion we came to is that the action necessary was to staff the EDs better.

because many of these patients that have those multiple protracted discharge issues were social admissions and

they really did not meet any medical necessity criteria, which is why we couldn't place them because they didn't qualify for anything.

So we really needed to step up the front door, have more of a gatekeeping process, make sure social work services and

discharge disposition from the ED was capable. And so that was a very important change. We have 12-hour shifts in the ED, and it has made a difference.

The other alignment or structural change that we made was bringing CDI into the meetings.

So you'll see in a minute that we have modified what many of you know as CARE, multidisciplinary rounds.

I'll show you that in a minute, but in order to achieve that, we really needed to see more alignment across inpatient case management,

centralized U.M., and clinical documentation improvement. They were all doing their work. They were all pinging the doctors.

And so the doctors were exponentially getting more and more queries every day from all groups.

And it was maddening, and they couldn't keep up with it. So we modified the physician advisor teams who were also reporting locally to the markets.

created a system physician leader for case management, NCDI, a combined role, and he then corralled, remodified contracts and

created a centralized physician advisor model which is very strong, and they are a very collaborative group.

And we trained everyone the same way. So again, the alignment, the resources have always been there, but the alignment and

the direction of the use of those resources is what was appreciably different. So this is the reference to the MDR rounds

The other thing we looked at internally. I began the MTR rounds at Hackensack back in the early 2000s.

So I am very much a believer in that model at that time when staff were available to stand together and walk the rooms together.

With COVID and with staffing challenges, that really became a thing of the past because no one had the time or staffing to do that the same way.

So we looked at how can we make these care expedition rounds. At the same time, we were changing our hospitalist teams.

We had new hospitalist contracts. And so we thought, what is a better way to get these teams, the care management teams, the CDI team, and

the hospital's team working together and getting to know each other than actually having them sit in a room together every day?

So we have started, we started at that time, these care expedition rounds is what we call them.

It's 30 minutes in a room together where they review every patient and what their plan is, what their initial assessment is,

what the discharge plan is, and if they are tracking to that plan. Two o'clock in the afternoon,

they re-huddle to see if there's been any modifications from the morning plan. So it's a dynamic model.

The outcome, outcome. They were working from a single set of planning and principles.

We used a tool that was part of the EHR but had never been turned on, so this is another optimization component.

that does give them visually the working DOG, the anticipated length of stay, pending lab test and discharge disposition, 

and oh, by the way, the admission diagnosis. So keeping that visual made it very easy for the teams to now focus on, number one,

the single admission diagnosis and not working up the natural history of everything or anything present on admission or prior chronic condition.

Laser beam focus on the reason for admission, and on the expedition of care based on the intercall reviews that they were getting from the CM,

the Care Management Resource Center, which has now become a normal daily activity. And I'll show you that in a minute

This I'll fly by, these are just functional. We also wanted to make sure we had high visibility on what were the key functions and

components of each team because there was incredible confusion. So this. This is for the care manager teams.

And then this one describes what we have for the physician advisors and the modifications that we created.

I'll go back for one second to the resource center. In the center, we have... the analytics support if you see here in the third box.

And it says drive opportunity, recognition, and resolution during daily and macro analytics.

Prior to this point, we did not have any unique analytics that helped to support any of these processes prior other than length of stay and

perhaps cost per case. So that analytic component has to be underscored and understood because creating visibility for the teams

actually helped them to refocus where they needed to. So we go back now to the admission, the single admission diagnosis and

our auto review function. So as described, we had the three teams all pinging the doctor at different times for different reasons,

sometimes the same query. It was highly into the medical staff and basically said, we need to do something different.

We need to have some discipline around the quote reason for admission as opposed to the present on admission.

There seemed to be some confusion in those realms. And, and the medical staff leaders did support.

the requirement for some discipline in that area, and we had modifications made to the EHR to allow a single admission diagnosis

and the possibility of a secondary diagnosis, but that was it. And you will see in a minute what the impact of that was.

So now let's just go to another polling question. What... Oh, who does your UM team report to? So you heard me describe medical officers.

We know some report to the CFO, some report to the CNO, or are there others? I'd be curious to know if you would please answer that question.

Can I advance? I'm wondering if I should advance at this point. Well, here we go. We have data. It looks like it's a very mixed bag.

Quite interesting, and this probably can lead to some of the discussion we have in the Q&A session.

For those who have other, I would really be curious if you wouldn't mind adding to the chat what those reporting relationships might be.

Thank you. So the impact of the admission diagnosis, what did it do and why was it important?

Basically it was a foundation for a clear treatment plan. We have care redesigns, we have care pathways, I think many of you do,

but if you don't have clarity on the reason for that admission. and you have patients with multiple chronic illnesses,

which in the early post-COVID era, we were dealing with a lot of unusual circumstances.

If you don't have clarity on that, then you do see the teams having- over utilization, working up all sorts of things,

not having clarity on the pathway or even an expected timeframe for the care and treatment.

So I think it's very important to have that clear admission diagnosis and then being assigned to the appropriate care pathway.

I often see heart failure, COPD, this, that, and the other, and people are really confused about which pathway they're putting a patient on.

So that helped with that. and the efficiency of the process.

What we didn't have was, or what we did have was frenetic care as opposed to that smooth clarity.

Then it did create a reactive environment and it was escalating all of those queries and pings to the doctors.

It was just non-productive and it was not sustainable. We went to the physician leaders.

Remember, now all of the case managers reported to the medical officers. So we went to the system-wide medical officer group and said,

here's the problem. And we need a solution. And can you support this change? And unanimously, they said, absolutely must be done.

Hands down, there was no debate. There was no concern. There were no power struggles. It was a yes from the beginning.

And then the deployment began. I will say that when you see the numbers in a little bit,

some of the only constraint that we had were folks who had standing orders serried away somewhere and continued to use them.

But other than that, we had really great support and amazing progress toward the new goal we had.

So the second part of the story was how do we really decrease the avoidable medical necessity write-offs?

And some of them were quite clear, but the again the centralized team were doing their reviews,

sending their reviews out to payers as required by contract, and yet not necessarily communicating to the inpatient teams.

So we said once again this is the team sport and it's an all in sport and you have to know each other's work and be responsive to each other.

Certainly getting the patient into the right level of care from the time they enter the facility starting with those ED case managers

and then moving forward through continued stay. We set up a tracking mechanism and daily reports.

I think this is very important for patients who were not meeting inpatient criteria. Patients in OBS who are sitting in observation status,

but did meet inpatient criteria. And you'd be very surprised at the number of those patients.

Observation patients not meeting any criteria who really didn't need to be sitting in OBS.

And if you have a centralized versus decentralized observation unit, that will matter a lot.

because you don't have eyes on the same way as if you have a centralized model.

And then observation that we're approaching the second midnight, and that was primarily for the Medicare patients to make sure we weren't

violating the two midnight rule. So those were the four categories. Now we'll start to get into some results.

So the workflow for that single admission diagnosis, you can see in the beginning, so this was January, 2022, we had four, 

no, sorry, that was the preliminary January 20, we had 4% of reviews generated. 2021, it wasn't much better. 

After we started doing that fourth quarter work, we really accelerated with having more clarity around the admission diagnosis and got to 78 percent.

Today, we're at, I believe, 82 percent and the reason for the lag are those.

those individual order sets that we haven't quite been able to collect them all and get them out of commission.

But pretty much I had made a commitment to get this level to 80 percent by October, and we did achieve that.

So I'm very happy. It has reduced an enormous amount of rework on everyone's part.

The second thing that happened though is it also, helped to decrease the hours to initial review by five hours, which is pretty incredible.

So when you think about when you're looking at your staffing and you're looking at your productivity, how do we get things quicker?

So we worked on accuracy, but then how do we work on productivity? And there is some... consideration about what is the right time to perform

your initial review, because you wanna make sure there's enough diagnostic information available to accurately do that and to form a diagnosis.

So we had set an internal goal of eight hours, and we've gotten to eight hours a little bit,

but what we're learning is that maybe eight hours is too soon, it might have to be longer.

So we've gotten now pretty steadily between 12 and 13 hours down from 17 and 18. stretch goal of 8 to 10.

Not sure that's the right goal though, so we would love to hear what some of you were doing in that realm.

The peer-to-peer process, which some of you know as the pre-billing denial, was also very, you know, somewhat disjointed.

because the denials were coming into the centralized team and the inpatient team had to manage them and

make sure we could get the provider on the call and with the payer, and that was becoming quite a challenge.

So we've modified that practice, revised the workflows there, and we've actually had an incredible uptick on recovery, 

dollars recovered due to better communication. You'll see the clinical information flow between the teams.

And... initially had a 42 million overturn in 2022, and we're continuing to track now to a 72% of a return rate with peer-to-peers and

the current or pre-billing denials. We do have the CMRC providing talking points and

information to both the Inpatient Case Management teams and the provider who's on the call with the payer.

That has strengthened their ability to articulate. And also, we are working with payers to allow our physician advisors to do some of that work

whereas previously it was only the only the attending themselves that had to do that

And as you know, when it's a surgeon or interventional proceduralist trying to find time to get them to do that can be quite a challenge

So we were losing cases and losing revenue really because of chaotic scheduling. And so that's been turned around.

When we talk about the CMRC team, they are using interqual embedded into our EHR, and

very easily you can see this information is embedded so the inpatient teams can see it,

and very quickly they know if a patient is sitting there who hasn't met criteria

And that stimulates a conversation with the attending or ED doctor, depending on who it is. 

but very quickly easily visible as opposed to here on the right, you'll see criteria met. 

Very simple. Excuse me, those blue lines are supposed to be covering the reviewer's name. I think that got modified.

So just before we send it out, if we can move that blue line.

The other thing we did was to create visibility was we created what we're calling pocket cards.

And we reviewed what the top 10 diagnoses were for the denials we were receiving.

And we created pocket cards based on the intercall criteria that the doctors carry in their pockets now. And the case managers as well.

We've done a lot of education for the ED teams with this now that we've had the visibility,

the ED teams, the hospitalist teams, and the physician advisors.

So they're much more conversant in the criteria and understanding what constitutes observation status, what constitutes inpatient status.

So it's a quick and easy reference that goes a long way. From a length of stay standpoint, we achieved a 0.9 ODE,

which is the first time the system has ever had the benefit of doing that. which was a stretch goal, by the way.

And so we achieved stretch in all but one hospital, as you can see. We do have a combination of critical access hospitals as well as others,

tertiary centers. And so the data is a little bit different there. We then looked at the CMRC team and we said, okay,

how well are we doing? We had some concerns from the inpatient team about accuracy and

we didn't know if it was a lack of understanding on the inpatient team side, 

or if it was that we were not applying the criteria as rigorously as we could have.

So we looked at, we did some audits, and basically the interqual pass rate for using the criteria is 80%.

I feel in a practical deployment way that that's just not adequate for seasoned reviewers and that we needed to have a more rigorous standard.

And so we started to add, we started to graduate to 90 percent and 95 percent. So you can see here in the beginning,

33 percent of the team were not hitting the 80 percent. So that meant at least 20% of their reviews were not correct.

89% of the next level here, 80% to 89%, 36% of the team. So 69% of our team were not meeting the standard that I created, which was 90% or higher.

31 third were. So most recently we continue this review. We continue looking at the IRR regularly and

45 percent of the team now score at or above 98 percent consistently. The overall average and that includes brand new staff is at 96.4.

And so we're really happy because we think we've moved the bar on this process. We have Educators, we call them leads,

who spend one-on-one time coaching staff and giving them direct feedback.

The reporting that we get out of the Interqual tool gives us precision on which reviewers are using the criteria or

multiple criteria, perhaps incorrectly, and so we're able to use those reports in order to drive that work and 

really move the bar on the accuracy. From a productivity standpoint, we were averaging about 28 is a day

And again, that means there's a range and the range was low for some. We were able to accomplish 31 in the prior year and now 32.5

but we have added new hospitals and 200 beds additionally without any. any new staff. And so there was an absorption of that,

which I think kept the number a little bit lower. We're looking for 35% as a goal. I mean, 35 cases as a goal.

And there are several folks who do 40 encounters a day. So we're happy about that.

And for the care managing coordinators who are doing the authorization work, they are doing about 40 per day.

We're very happy with the accuracy and the productivity of the teams and the centralized team.

We're seeing the same impact then on the inpatient teams because they can really count on what they're getting.

Finally, we'll talk about achievements and then we'll be ending shortly. Overall achievements is the authorization denials reduced by 70.8%.

half of your battle for your overall denial rate is going to be eliminated.

The level of care write-offs for medical necessity reduced by 76 percent. Peer-to-peer, I showed you right now, it's about $54 million in recovery.

That otherwise would have been lost. The Medicare short stay right off reduction happened.

It's about a half a million a month and growing because we're getting a lot more attention there.

In California, we have a lot of managed groups who do manage care work with these patients and they like observation status,

but they also like to keep them there a very, very long time or, you know. other behaviors that go along with that.

So this one we're watching closely. For the approaching to midnight rule component of that work,

we have made great strides in getting that right and really making sure the change are including condition code 44 and

those other regulated items that we need to pay close attention to. So we saved over 10,000 opportunity days.

through the efficiency and those on-site MDR rounds. And so. That was just for 2022, it was about $6 million.

And you saw that with the length of stay. So this is great. The financial officers are quite happy and the efficiency is showing.

The other thing it allows us to do, of course, is admit those patients who need to.

So when you look at that criteria of patients sitting in OBS who can be converted to inpatient, number one, it's appropriate.

Number two, it's financially responsible. And for the patient, they're not paying out-of-pocket copays from sitting in OBS and

having, you know, expensive diagnostic for everyone, and I strongly encourage that you pay close attention.

So you can see the process efficiencies. I think I described these as far as we did redesign work. really documented sustainable workflows.

We took some of the chaotic work, some of the variability, and a lot of the other duties as assigned taken out.

Okay, so much more efficiency, better data transparency, and then the overall reduction in AR days an

medical necessity denials was a big win for the finance teams. So the sustainable achievements going on, those early achievements, by the way,

those are 2022. So that was a direct result in the same year of the work that was done.

And then the ongoing sustainable, so we're continuing the workflow. We have sent the case management teams back to the market,

so it's no longer a shared service. They are back to the markets. They continue to report to the medical officers

But they are now a market based. employee once again, but we sent them back with standard work. And for the inpatient case management team,

the two key drivers are length of stay efficiency and denial reduction. Denial reduction prior to this work was not part of their consideration.

Okay. So basically, the inpatient auth denials continue to be reduced since that fourth quarter of 2021.

The write-offs, the avoidable write-offs have reduced from 2022 to 2023, almost 37%, which is amazing.

And the breakdown here is almost 46, 47% in the inpatient write-offs, which started as a scheduled visit, i.e. a surgery, an ambulatory surgery

that for some reason gets flipped into observation status or stays overnight as an inpatient.

We've really gotten some good traction there. The 28% reduction in avoidable Medicare write-offs and 

then 27% reduction in the mom-baby. avoidables and a lot of that have to do with timing of discharge.

They were just not being efficient about tracking those 48 and 72 hour rules. So that's been a great help and

there were some logic changes that we had to do in the tool in order to accomplish that.

We had a 20% increase in the conversion of those OBS patients to inpatient. So that was You know, that was great on many levels

One, it was much better patient care. The second is it was financially much better for the organization.

Almost 19% in the increase of the Medicare secondary review encounters and applying the two midnight rules better, as I mentioned, and

then 42% in peer-to-peer charge overturns in 2022, and then 72 million in 2023 thus far. These are real dollars.

These are real dollars, and this has really had a positive impact system-wide on the fiscal health of the organization.

The clinical denials are now at less than 1%. whereas they were extraordinarily high. I won't even tell you how high they are,

but that is an enormous improvement on the prior circumstances. And then finally, what I have not mentioned previously is the interactions with payers

So typically there are facility meetings or... RevCycle meetings, payer meetings that occur or contracting meetings

, but we really felt it was necessary to have a UM-focused meeting. We have over 3,200 different contracts with different payers, and

we felt it was really important to rationalize that and to get to know the teams and to let them understand where we were experiencing challenges and

to hear their perspective. What was very interesting is in many of these, once you get up close and comfortable with they tend to share a lot.

Many of them did talk about their own staffing challenges and the ability to keep up with the rules that they create.

Okay, so one was. We had the conversation about if you can't do a final determination, for example, within 45 days, then you need to pay us

You know, I'm sorry having staffing issues, but you need to write a check. So we've had very practical conversations with them.

We did understand workflows, something as simple as updating contact information, making sure faxes were going to the right place, 

make sure portals were working, etc. But it really helped the teams to get to know each other, to escalate and

how to really reduce anything that was going to have a negative downstream impact. And you saw the results for the authorization denials.

It has made a tremendous positive change. So I think with that, we can end there and leave some time for Q&A.

I think there's one final polling question. And that is, do you have dedicated UM team? JOCs or join operating committees with your payers or

some form of ongoing communication where you actually get to speak with each other. So if you wouldn't mind answering yes or no,

I would appreciate that and then we'll get into the Q&A. And it looks like we have 30 questions building, so let's get that done.

And thank you for your attention. Riz, can I move forward now or should I wait a bit longer? Yes, absolutely. Okay.

So, okay. So, a little bit more than half are having those meetings. Great to know. Okay. With that, why don't we close and move on to Q&A.

Thank you, Regina, for a great presentation. We will now begin today's question and answer session. 

I would also like to introduce Andrew Jacobson, Interim CMRC Business Operations Director at Adventist Health System,

who will also be joining us for the Q&A. As a reminder, you can submit any questions you have by typing them to the Q&A chat box

on your webinar console. Let's get started with the first question.

When did you require the single admission diagnosis to be entered by the ED doc prior to admission on the admitting doc on the floor?

Oh, that's a really good question because technically, ED docs don't have the right to admit, right? 

By medical staff bylaws, it has to be a doctor with admitting privileges and that does not include the ED unless your bylaws say it does.

So I would check that number one, but typically they don't, they are there to stabilize and recommend.

And that was a large part of our education and training is that ED docs can recommend,

but it is either the hospital's team or the inpatient attending that has to make that, you know, definitive definition.

And that's where waiting a while for the criteria and the diagnostic tests to come back really helps because you know,

instead of trying to rule out, you actually know what you're trying to treat. I hope that answers your question.

Thank you. Great. Another question is, is it good to help on the center? It currently is and has been since 2013.

Thank you. How will the change to Medicare Advantage plans following the two-midnight rule come January change your process?

I don't think it's going to change our process. I think it's going to have a significant change on those managed care entities.

But what we do expect is higher volume and need for higher-level interventions, 

particularly as it is going to have more tighter enforcement on that two midnight rule

So those cases, remember we have the tracking mechanism now and I didn't mention to you that every day the finance officer, the medical officer,

the care management leader and the physician advisors get a list of every escalation sent out to the teams.

So patient doesn't meet criteria, a note goes out to the inpatient case management team and this aggregate report daily goes out to those leaders.

so that they can understand what's happening at higher visibility and intervene. They've been able to course correct quite well.

We do anticipate this area to jump quite significantly. There'll be a lot of initial activity and

we are starting to socialize with those managed care entities and managed care contracting groups and

the presidents and finance officers and M.O.'s at the hospital level because it will affect those hospital contracts that they have

but we do plan on following the enforcement rules that Medicare is setting out. Thank you so much

Our next question is, our JOCs are more billing focused. Were you able to have just you in focused meeting

I can take that one, Regina. Go ahead, Andrew, please. Yeah, go ahead. Yeah, so I think the big challenge there is actually finding the right contacts.

And so I think, you know, the question kind of alludes to the same pattern we had or experience we had where we would join kind of a claims

JOC meeting, try to ask questions about the UM space and we would get told that there wasn't anyone that could ask or answer those questions and

they need to find someone for us. So it's been a bit of a challenge to navigate that.

Some payers are much more responsive to getting someone on the phone with us than others

But I think once you do have those people on the phone, it opens you up to a lot of optimization.

And we've just found that we're finding all sorts of new things we can try or collaboration activities we can do with different payer

to get to a more streamlined process. But the challenge we did face is kind of finding the right contacts, you just gotta push for them to get them

And some payers will have different UN contacts by product. So Anthem, we have four different meetings with them because

they have a different UM team for commercial, two different commercial teams and then a team for each of the managed Medicare and

Medicaid products in California. Hope that answers that question. Yeah, and Andrew, I wanna add a little bit to that

So typically we have their medical director and ours because they head up that clinical component.

And so I think Andrew's right, it's the precision and the right people in the room.

And so we started with the busiest, you know, largest payers and four meetings sound like a lot, but we, the frequency diminishes over time.

It's really those initial meetings where you set the stage and learn how to work together better. Right, Andrew?

Yes. Yeah, for sure. Yeah. And there are little interesting kind of anecdotes that we have from each of them.

You know, each of them, we've come out of them going, oh, that's not in the provider manual. That's not in our contract.

But if we do X, all of a sudden we get faster off determination, better peer to peer outcomes

So we usually have a kind of a plan that comes out of each of those initial discussions that we then build and tailor the solution around.

So it's a little bit frustrating to have to have some differences between how we work with different payers,

but certainly getting that information and being able to act on it has been really beneficial to the health system.

Yeah, it eliminates a lot of... a lot of extra work and a lot of redundant back and forth that really has helped tremendously

And they're more tolerant and kind to us because they know that we're really collaborating. So what's the next question, Riz? 

Fantastic. Thank you both. The next question is, did you see a change, increase or decrease in your observation rate?

best change and decrease because there was that group of patients who really didn't meet any criteria, including OBS.

And so we were able to, especially with that 12 hour ED case manager, to do better dispositioning earlier.

Okay. So that in that category, but also the patients who met inpatient criteria that was sitting in OBS, we moved forward.

And so the they moved out in both directions better. So it does affect the overall rate and we are monitoring hours in ops now as well.

And that has been diminishing. And Regina, the other thing I'd add to that is the using the analytics from what we're getting out of Interqual and

using all of that data is really what kind of pointed us to those opportunities. So we were able to look at it and see that we were escalating

doing all these escalations where the patient sitting in OBS meets inpatient and nothing's changing. We're not converting that to an inpatient.

So that started getting socialized in different UM committees. And that's really driven that conversion rate up, 

but we have tracking now around that where we can report out to each market, how are you doing against that type of escalation? And that's.

That's really where I think we've seen a lot of that improvement. And then same with the other side,

if someone's sitting in OBSBED and doesn't meet any criteria, and we actually act on those escalations, we see that OBS rate change

So the data transparency is very important. And I think what we didn't mention, there's just a lot of content that goes beyond what we talked about today.

But we also created a standard U.M. for use across the system

And those data that Andrew just referenced are sent from the central team to the onsite teams for the U.M. committee meetings each month.

And so the data visibility and the understanding of how to prioritize the work that has to be done has really been a great improvement and

that's where we're getting the traction. Do we have time for another one, Liz? Yes, we do.

The next question is, how much of a role does the integral automation tool play in your project success? Oh, very, very much so

So number one, the auto review begins with the efficiency and the time to actually time to initial review.

The accuracy of the reviews, you know, many of the onsite teams that I know into call. I'll do it

And some of the work being done by the resource center, we can track and meet regularly with the teams, with the interqual team

with Ian and his colleague Christine, looking at those types of circumstances where we're seeing manual reviews being don

, trying to override the auto review. And we look at those circumstances and actually spend a lot of time understanding that and

 refining accordingly. So there's a lot more. additional types of reports that get us down to a level of precision

 because as we've been doing this it's like peeling the onion. The standard work is there and now we have some new questions about and

 what else what's left for that refinement space. Fantastic. Well, thank you. That is all we have time for today.

 I'd like to thank Regina for sharing great insights and Andrew for sharing their insights during the Q&A.

 And many thanks to Opcom for sponsoring today's webinar. To learn more about the content presented today,

 please fill out the post webinar survey and check out the resources on the resources console.

 Thank you so much for joining us today. We hope you have a wonderful afternoon. Thank you. Thank you.