Driving to a healthier bottom line through UM optimization

How a utilization management overhaul impacted key metrics 

“From these very deliberate efforts has come a cascading, positive effect that just keeps going.”

— Regina Berman, RN, Value-Based Care Executive, Adventist Health West, Glendale, CA

To become more centralized and efficient, Adventist Health West (AHW), a 25-hospital system serving patients in California, Washington, Oregon and Hawaii, overhauled its utilization management (UM) program and has seen sustainable changes that continue to positively impact key metrics related to patient outcomes, staff satisfaction and healthy financials.*

Utilization management challenges

AHW saw the need to increase efficiencies across its disparate organizations through UM centralization, technology enhancements and workflow optimization to improve its bottom line. Prior to the COVID-19 pandemic, UM and inpatient case managers were heavily siloed and saw little success implementing new processes and technologies, even though they were all on the same campus. With the pandemic’s drive to remote work, the siloes became harder to penetrate, and the disconnect among teams, processes and technology was exacerbated, preventing them from addressing their poor financials.

Health system leadership realized what was needed was a more centralized UM model, incorporating standard workflows across all the system’s hospitals, and technology that would increase efficiencies. They also wanted a clinically driven initiative that would have a positive effect on the revenue cycle, resulting in fewer avoidable medical necessity denials, reduced length of stay and healthier financials overall.

In addition, technology that was implemented prior to COVID-19 was being underused. Staff had access to the InterQual® AutoReview cloud-based solution, which was intended to be used for medical review automation. However, Regina Berman, RN, value-based care executive, Adventist Health West, Glendale, Calif., and colleagues discovered that only 4% of reviews were automated.

“We realized that the way the physician order process was built in our EHR was not ensuring a single order for admissions flowing through, which is what would trigger the technology,” Berman says. “We knew we needed to get together with the medical staff and make a dramatic change in their order-writing process.”

Forward-thinking UM solutions

In 2021, leadership decided to implement improvements across all 25 hospitals at once. Some of the most significant moves included:

• Clinical workflow changes, including: insisting a primary condition-specific admission diagnosis be documented; cross-functional collaboration among the UM, clinical documentation improvement and care management teams; correct use and increased adoption of InterQual criteria (evidence-based criteria used to help ensure clinically appropriate medical-utilization decisions) across teams and physicians; and a right-sized peer-to-peer review process, with improved completion and overturn rates.
• Technological changes, including: refinements in the EHR to require the single diagnosis is entered on the admission order, and full use of InterQual AutoReview for automated medical necessity reviews, which reduces the manual burden on staff and increases review accuracy.
• Utilization review workflow changes, including: a streamlined escalation process that more accurately, and immediately, places patients in the right level of care and enables the UM team to communicate escalations to on-site care teams more quickly.

The impact on outcomes

In addition to a better care experience overall for patients, who are placed correctly more quickly, staff have experienced greater satisfaction in their work and feel more productive thanks to more sustainable workflows and processes.

“From these very deliberate efforts has come a cascading, positive effect that just keeps going,” Berman says.

Other notable outcomes include:

• Increased generation of automated InterQual reviews via the InterQual AutoReview solution from 4% of reviews automated to 78%
• Increased productivity, from a goal of reviewing 35 encounters per day (in 2022) to a team average of 40 per day
• Reduced accounts receivable and medical necessity write-offs, which resulted in:
  • Authorization denials reduced by 70.8%
  • Inpatient medical necessity/level of care write-offs reduced by 76%
  • Peer-to-peer (concurrent) denial charges overturned ($78 million total)

Key UM lessons for health care leaders

Berman has the following advice for health care executives:

• Have the right partners at the table. Stakeholders on this initiative included UM leaders, physicians, senior medical officers, revenue cycle and clinical informatics staff, hospitalist groups and vendors.
• Get physicians on board. A cornerstone of the improvements was asking — and then requiring — physicians to enter a primary admitting diagnosis. Because this was a change to their regular clinical workflow, earning physician engagement was critical. Adventist’s physician leader group agreed to educate and get other physicians on board.
• Don’t underestimate C-level support. As a member of the C-suite, Berman’s leadership on this initiative sent a strong message that it was a priority. Facing the challenges together as a unified leadership team also was key. “When leaders come together, the teams come together,” Berman says.
• Focus on data — and transparency. Data has been essential for AHW’s ability to evaluate progress and refine processes. Case management leaders, medical officers and financial officers receive patient escalation reports for each patient daily, delineated by reason and provider. Staff also receive weekly, monthly and quarterly reports, furthering transparency and staff’s ability to find and correct issues.
  
  “Each leader has what they need to make the next right decision,” Berman says.