On-demand webinar
MD Perspective: Reducing the burden of costly secondary reviews
Explore how objective criteria, strong clinical documentation and automation can help improve workflow efficiency, generate time savings and enhance secondary review.
MD Perspective Webinar Recording
0:00
Thank you so much and thank you everyone for joining.
0:04
Yes, my name is Doctor Linda Everett and I am the Senior Medical Director for the Interpol Customer Experience team.
0:12
And my background includes being a board certified internist.
0:16
And as an internist, I did work in primary care as well as as a hospitalist.
0:24
At that time, I also worked in utilization management as a physician advisor and then did that full time as a medical director and most recently working working for Interpol, working on the Interpol team, focusing on physician education, consulting and nurturing our customer relationships.
0:49
So let's get started.
0:50
For today's topic, let me start with something most of you have experienced.
0:57
A case is flagged because it meet its its merits for medical necessity are unclear at best.
1:06
At worst, they're non existent and everyone involved already has a pretty good idea of how this case is going to end and what the outcome is going to be.
1:16
But it still moves through utilization review, physician advisor review, It still goes to peer-to-peer.
1:22
Sometimes it goes to appeal.
1:24
And not because the case is so clinically complex, but because the process did not give us a better option.
1:32
So that's not a clinical failure, that is a workflow failure.
1:36
And over time, these failures add up.
1:39
They add up to more denials, more rework, and more physician time spent defending decisions instead of making those decisions.
1:48
So today we're going to talk about using the secondary review process with intention because when secondary review becomes a routine step as opposed to a precision tool, it creates burden without value.
2:09
So let's go over our agenda today.
2:12
Over the next 45 minutes or so, I'm going to walk you through where that burden is coming from.
2:19
And also we're going to talk about what high functioning workflows look, how those workflows look different.
2:25
Also how to reserve physician expertise for the cases where it actually matters.
2:32
We're going to start by reviewing the state of the industry that shapes some of these challenges that we're facing, followed by clarifying the realities of observation versus inpatient level of care.
2:45
We're going to reinforce those with some case examples.
2:49
After that we're we will discuss strategies for optimizing your UN processes to achieve desired outcomes, whether those outcomes are accurate accuracy improvements, denial mitigation or increased efficiencies.
3:10
So here's just a depiction of that perfect storm that creates the environment that we are dealing with now.
3:17
Denial rates are rising.
3:19
Some payers have reported denial rates of greater than 20%.
3:24
Caseloads are increasing and they're demanding higher levels of productivity with fewer humans to do that work.
3:34
And let's not forget that the administrative burden is just getting heavier.
3:39
Financial pressures can create competing priorities of affordability versus quality patient care.
3:48
It's always that balancing act, always walking that fine line.
3:54
And one of the broad products of all of this is we have highly trained physicians that are spending time on low value work.
4:04
We're asking physicians to spend more time justifying these decisions that they're making as opposed to thinking critically about them.
4:14
And what that's doing is it's contributing to physician burnout.
4:18
It's decreasing their satisfaction in the work that they are doing.
4:23
And it it it overall makes physicians question why did, why am I here?
4:30
Because I'm not really using my clinical acumen.
4:36
How many of you just think about that?
4:39
Thinking about that, how many of you feel like your physician advisors are being pulled into cases that don't really require their level of expertise?
4:48
And you don't have to answer out loud, but I want you to keep that in mind.
4:52
Or you can drop your opinions in the chat in the chat because I'd suggest to you that that is where the opportunity lies.
5:05
So here I have your typical hospital admission workflow.
5:12
So if I can point out here, we have that the the patient is admitted and then there's AUM process we request, we request a particular level of care and then sometimes it's authorized, sometimes it's not.
5:32
We can submit a claim and the the claim is paid, but in that workflow there are a few common areas of abrasion that are increasing that administrative workflow and this is how it affects the physician reviewers.
5:48
So here we have two common friction points.
5:52
First, we have this internal abrasion here in that UM process, and that's the internal friction amongst the UM nurse, the physician advisor and the provider.
6:07
The nurses usually need answers sooner rather than later so that they can complete their work, get through their queue.
6:14
The attending physicians have patients to see and they really prefer not to be bogged down with inquiries from the UM team.
6:23
And then we have our physician advisors who are basically being asked to spin straw into gold.
6:30
So that's our first friction point.
6:34
And then after that authorization request, if a denial is, if a denial notification is rendered, then we have that external abrasion.
6:46
And this is through payer and provider interactions that are not always as pleasant as we would like.
6:53
It really should be a collegial peer-to-peer discussion, but it can turn sour for various reasons.
6:59
Maybe there's a lack of trust in the information that's being provided or maybe there's just a sheer lack of information.
7:09
So as AUM physician advisor, I found myself explaining the concept of observation level of care to new hires as well as providers multiple, multiple times a day.
7:24
And now even as a consultant, I continue to hear this pushback from clinical leadership.
7:31
So I'm happy to just once again give some more clarity to try to help with this misunderstanding of the definition and the intent behind the observation of level of care, so we can clear that up.
7:46
So common perceptions are that observation can only occur in a designated observation unit, or that extensive and thorough evaluation and treatment plans can only happen while in inpatient status, or that inpatient admissions always result in a higher patient, higher payment to the hospital regardless of what the contract looks like.
8:13
But the reality is that observation is simply an outpatient reimbursement for a patient that is in a hospital bed.
8:25
And depending on the contract, sometimes the payment equals greater revenue than that of bundled reimbursement for an inpatient stay.
8:38
Any hospital bed can function as an observation bed.
8:43
And the intent of observation is to provide the necessary care, the tests and the procedures that are needed to evaluate relatively stable patients and determine the need for if there is a need for more intense and longer monitoring and treatment.
9:02
And the icing on the cake here is that when it comes to choosing observation status, there you have a decrease in denials and thus decrease in administrative costs associated with the secondary review process that's resulting in higher overall revenue for the hospital.
9:32
So here is again reinforcing kind of one of the problems we're trying to address here is that physician advisors are being used as a backstop for these gaps and processes.
9:46
And what that means is that high cost clinical expertise is being applied to cases that have predictable outcomes and over time that leads to burnout, inefficiency and frustration.
10:07
So let's take some few moments to view a couple of common scenarios.
10:14
And in those scenarios, we're representing our two major levels of care observation and inpatient.
10:20
And we're going to talk about how some key changes in the workflows and also how the effective use of evidence based criteria can impact have a great impact or a negative impact depending on which way it goes on your precious position advisor team.
10:41
So here we have Steve Smith.
10:44
Steve is a 56 year old who came into the Ed with chest pain, with exertion.
10:50
He was mowing his lawn.
10:53
He has some risk factors of hypertension and tobacco use, and on physical examination he is slightly hypertensive.
11:02
150 / 100, otherwise unremarkable.
11:07
His cardiac enzymes were negative.
11:10
No acute EKG changes, nothing on chest X-ray that was remarkable, and his chest pain did resolve with some nitroglycerin.
11:19
So the physician's assessment was chest pain.
11:22
They wanted to rule out MI and the plan is to admit this patient to inpatient level of care, place him on telemetry, do some serial cardiac enzymes, aspirin and stress echo.
11:35
So here ladies and gentlemen, we have an observation patient that is trying to be forced into inpatient level of care.
11:47
And before I go through what happens, I'd love you to take a second and think, what would you do with this patient?
11:54
Would you escalate this to the secondary reviewer?
11:58
Would you attempt to downgrade prior to that?
12:04
Because this is the exact decision point that your teams are going to face be facing on a daily basis.
12:17
So this is this is a common scenario of how this will go.
12:22
This patients admitted to inpatient, there's AUM process and the patient doesn't meet for inpatient patient only meets for observation.
12:32
So now the patient, the patient is routed to secondary review.
12:39
The physician advisor, excuse my marks there.
12:42
The physician advisor knows that, you know, this patient really is only appropriate for observation, but the directive is to justify in some way, way, shape or form inpatient level of care so that we can proceed with this submission in this request.
13:02
And lo and behold, there's a denial.
13:06
So now we have, we go in this cycle of a peer-to-peer process.
13:12
The peer-to-peer is done, There's no additional information and now the denial stands and maybe this may go to appeals.
13:20
And here's the problem.
13:23
All of this work and this this claim is still paid at observation level.
13:29
So every time we enter this cycle, we are creating the illusion of value and it feels like important work is really happening.
13:40
But in reality, what we're doing is we are delaying an inevitable outcome.
13:48
Now let's multiply this across hundreds of cases and there we have our real cost.
14:02
Now let's look at an alternative route here, same patient, but a different decision.
14:09
So instead of trying to force inpatient level of care, once we see that this patient meets for observation of the secondary reviewer is able to change the status to observation level of care.
14:27
That's what's authorized, that's what's requested, that is approved and the pain that they claim is paid as observation.
14:38
So voila, we we're eliminating that churn.
14:45
There's much less stress placed on the physician advisors and there's also less conflict between the payers and providers over these peer to peers.
14:55
So now we have fewer exact fewer expenses and a greater net revenue.
15:00
So this is what eliminating unnecessary secondary reviews looks like, and this is also where process improvement can create an immediate impact.
15:18
Let's look at a different case.
15:20
This time.
15:21
We have a patient with Cellulitis.
15:23
This is Alicia Adams.
15:25
So Alicia is a 73 year old who came to the Ed with redness and tenderness of her left leg.
15:32
She had been taking Keflex 3 days prior with no improvement in her leg, so she was admitted to the hospital for Cellulitis.
15:43
She does have chronic venous stasis as well as heart failure with reduced ejection fraction, diabetes and diabetes, diabetes and hypertension.
15:56
Her physical exam is remarkable for pre tibial edema which is diffused 4 by 6 centimeter raised area.
16:07
It's warm and tender to the touch.
16:10
She has a slightly elevated White County.
16:12
Her blood sugar is 300 and her hemoglobin A1C is 9.2.
16:18
She was ruled out for DVT so they admitted this patient to inpatient level of care again with the diagnosis of Cellulitis.
16:25
The plan of care being IV antibiotic zosin and blood cultures and placing her on sliding scale insulin.
16:42
So this is where we see this.
16:47
This is really where the physician can add a lot of additional value in this situation of Cellulitis is really one of those diagnosis that is typically thought of as an outpatient diagnosis or observation diagnosis.
17:05
There are a few exceptions and sometimes those are immediately recognized by the payer and sometimes they're not.
17:13
But this is one of those.
17:14
This is one of those scenarios where this patient really does require and meets medical necessity for inpatient level of care.
17:22
I'll show you that in the next slide.
17:24
But it's not unheard of for a case like this to be denied at first, even though the patient does meet criteria.
17:32
This we wouldn't initially need a secondary review because the patient does meet criteria.
17:37
Or it's possible that the patient the on primary review, because of the subtleties that may go to secondary review as well, just to for the secondary reviewer to find that the patient does meet criteria.
17:53
Either way, if this case is denied, then it's going to go to peer-to-peer.
17:59
And because of the documentation, we have a collegial peer-to-peer conversation, the provider would resend this denial and the claim is paid as inpatient.
18:12
And I'll show you what that looks like.
18:19
So here on the left we have our we have our Interpol criteria for the Cellulitis subset.
18:31
So when we're looking at Cellulitis at the acute level of care, you have to have the finding and you have to have the intervention.
18:41
So at the acute level of care, if a patient is immune compromised, which is defined in this case by poorly controlled diabetes with the hemoglobin A1C greater than 9, which this patient had, then that meets for that finding, and and then the patient is going to get the of course, the anti infected.
19:07
So this patient really does meet for level of care because of the comorbidities and complications intrinsic to this patient.
19:16
This is a nuance that can be easily missed, especially when we have common payer policies that may initially place all Cellulitis cases into an observation level of care bucket.
19:29
But again, because we have the the information so clearly documented and it's so clearly laid out, this should be an easy peer-to-peer conversation with an easy overturn.
19:49
So this is what it what it may look like for the physician advisor when it comes to the peer-to-peer because we can leverage our Interpol review summary.
20:00
So this is a review summary perhaps was done by the primary reviewer and it shows with the check marks what criteria was met.
20:10
We have immunocompromised.
20:11
We have a reviewer comment showing that A1C.
20:15
Was 9.2 and we have the anti infective and we see that acute criteria was met.
20:24
So again, it gives that outline for that very structured, very objective, and it really should be very efficient peer-to-peer conversation.
20:33
And this is where physicians should be spending their time because when documentation and criteria align, the peer-to-peer conversation is not adversarial, but it's productive.
20:54
Let's go to this third case here.
20:57
This is Teresa.
20:58
She's a little bit more complicated.
21:01
Teresa is a 68 year old presenting to the emergency department with dyspnea, orthotnia and lower extremity edema.
21:10
She was given Lasix 20 milligrams IV and admitted for congestive heart failure.
21:17
She has a history of coronary artery disease with the EF of 40% diabetes, COPD with not on home oxygen and chronic kidney disease.
21:28
So she received some Lasix in the Ed appearing comfortable after that rest.
21:35
After receiving her Lasix and her create, she has a normal electrolytes labs unremarkable except for this.
21:43
She does have chronic kidney disease with this creatinine of 1.9.
21:47
Her initial troponin is a little slightly elevated at point O 6 in the setting of that chronic kidney disease.
21:54
Upper limit of normal notice would be point O 4.
21:57
Chest X-ray shows no pleural effusions but there is some pulmonary vascular congestion.
22:03
Right bundle branch block on on EKG and the plan of care is inpatient level of care Lasix 20 milligrams IV twice daily supplemental oxygen nebulizer treatments follow her troponins as well as her electrolytes and creatinine and a 2D echocardiogram.
22:30
So if we can think about how, how we would, how we would approach this patient, but I'm going to suggest this one is not clear cut.
22:46
So what I would advocate for this patient is if if the initial order is for inpatient, if you look in inter qual, you're going to see that a criteria is not explicitly met there.
23:03
Even though this patient does have Co morbidities, you could argue for exercising clinical judgment predicting that the patient is going to require a longer stay.
23:14
However, we can oftentimes predict also that this is going to be a denial because of the greatest of this case.
23:24
So one way we could look at this is to proactively on secondary review, downgrade to observation level of care, avoiding that denial and prioritize this case for a continued stay review.
23:44
Optimally on day three is where you would expect to either be discharging this patient or upgrading them to that higher level of care.
23:56
So let's see how how Teresa manifests here, how her how her disease process plays out.
24:04
On day three.
24:04
She reports dyspnea on exertion and orthopnea is unimproved.
24:10
Her O2 saturation is 91% on room air still having significant lower extremity edema.
24:18
The UN is 43 and creatinine is 2.2, which is an increase from that 1.9 remember at admission.
24:27
So we are assessing that the patient has unresolved congestive heart failure, acute on chronic and she also has pre renal azotemia on on top of her chronic kidney disease secondary to her diuresis.
24:43
So we're going to adjust her diuretic medications, add Aldactone, we're going to monitor her labs more closely, get a nephrology consult for fluid management.
24:55
So in this case observation, not necessarily we don't want to look at it as a failure or uncertainty.
25:05
It's really intentional timing.
25:07
It's a strategy.
25:15
So this same case on at the time of admission, she clearly failed observation level of care and now requires a higher level of care on episode day three.
25:30
So I want to kind of show you how this works here and how this workflow is for those who may not be used to seeing inter qual.
25:39
So in our in our episode day three for this patient, we have that this patient is a non responder.
25:49
And what that means is that she is still having symptoms and she's still requiring hospitalization because on day three or which is that should be the end of this observation period, she should be able to be discharged, but she's not stable enough to do so.
26:09
So what we direct you to do is go up to this higher level of care, which is acute and then you can show that the patient requires that level of care by showing her signs and symptoms.
26:23
So we she still has dyspnea, she still has lower extremity edema.
26:29
She also has the elevated creatinine requiring net fluid management.
26:35
So now on peer-to-peer or or on proactive requests, we can easily get this patient upgraded to an inpatient level of care on episode day three.
26:50
And again, we have this review summary that can be served as a a succinct document to support that, to support that discussion and just also to support that decision making.
27:11
So now we have the rest of the process that goes through fairly, fairly smoothly.
27:20
The patient can be upgraded to inpatient and we're going to receive authorization for that inpatient stay based on that concrete, concrete clinical evidence.
27:30
This is the same patient receiving the same care, but now it's defensible.
27:34
And now we avoided that all of that friction and abrasion.
27:45
So let's discuss how we can implement these best practices at your organization.
27:54
The goal really is better timed decisions.
27:59
So there's five steps here.
28:04
The five steps is everything that we've discussed here.
28:09
I've seen them across multiple organizations, different sizes, different payer mix, all the same problem.
28:16
So the the crux here is to have data-driven determinations.
28:23
Next, we want to support that secondary's review process, empower your physician advisors in that process so that they can work at the top of their license.
28:34
You want to be proactive about those continued stay review workflows specifically in the observation level of care.
28:42
We can leverage automation to also help and increase with this efficiency and then and then leverage data so that we can inform and and continue improvement initiatives.
29:03
So this is just an example again of what the features of intercall criteria have in terms of that objective data so that we can get that those data-driven to determinations.
29:18
Here you can see that there are risk factors that are clearly defined, they're supported by evidence that we we have objective clinical manifestations requiring that documentation and then the interventions that are required to support that level of care.
29:40
So you can see all of those things we can, you can also when you're using intercall, indicate things that didn't happen.
29:47
So criteria that is not met that can also be recorded.
30:01
And by having this precision here, we're avoiding ambiguity.
30:08
Ambiguity it creates, it drives variability, variability drives denials, but rather these objective data.
30:20
So what is the what are the thresholds, for instance, for for the number, the frequency of medication?
30:28
What is the, what are the specific granular findings that are being caught that are being documented?
30:38
What is the actual O2 SAT?
30:40
What are those thresholds?
30:42
Those are things that need to be clear so that you can have consistent outcomes.
30:48
So objective data creates defensible decisions.
30:51
If you don't have these clear thresholds, you have inconsistent outcomes.
30:57
And I want to point this out because that's one of the differentiators with inter qual criteria is because it is so specific, it is so granular and it is objective as often as we as we can while including some flexibility.
31:15
It makes it allows everyone to be on the same page and to be discussing the same things so that we can come, so that we can have defensible rationale.
31:30
They these data determine the driven determinations allow for these efficient peer-to-peer conversations.
31:39
They also support that inter rater reliability, meaning that you know multiple providers reviewing the same case will come up with the same result.
31:52
It also it also effects compliance and audit readiness.
31:57
And of course is the world of AI is already in the UN processes that objective criteria will does support that transition while still maintaining the transparency of the criteria.
32:12
There are other solutions where there's black, black, black box technologies where you may get a score or a yes or a no, but you don't really know the reasoning behind it.
32:25
Whereas Intercall is very transparent as to how we come up with those decisions.
32:37
So to support our secondary reviewers, what we ask and what we recommend is stop sending more cases, start sending better cases.
32:51
So let's improve the case quality before we escalate them.
32:55
We want to make sure that the primary reviewers are submitting complete and organized clinical summaries that are aligned to that criteria.
33:06
Let's standardize what needs to be included before a case is even routed for secondary review to make sure the vitals are there, show the response to treatment, show the diagnostics, show the timelines and reduce the noise so that the physician advisors can focus on the true ambiguity as opposed to trying to clean up documentation.
33:37
Next, we want to triage and prioritize.
33:39
So secondary reviews should be reserved for true clinical ambiguity.
33:45
Only route those cases that are high value, meaning they're complex or maybe there's a there, there poses a specific risk to that particular knowing that particular payers behavior.
33:59
They may be higher risk because of that or maybe they are outliers, prolonged stays while deprioritizing cases where it's clearly observation and unlikely to succeed on appeal.
34:16
And thirdly, we want to we want to support our P as to recommend that status reassignment so we can establish some clear governance allowing P as to perhaps get a status change to observation when criteria is not met as opposed to trying to force that case into inpatient.
34:41
We want to normalize observation as an intentional, intentional and proactive strategy and not a failure.
34:49
And all of this comes down all this keeping in mind reducing those futile peer-to-peer cycles that are going to end in what we know is going to be a denial workflows.
35:08
The most successful organizations routinely review all of their house, all of their observation cases on hospital day three, sometimes hospital day two and three.
35:22
And the reason this works especially with inter qual criteria is because the criteria is written in an episode day structure.
35:31
So that makes it relatively straightforward to follow patients along the continuum of care because as we progress to the next day, the criteria adapts based on the clinical progression and that patient's response to care.
35:48
So what this does is it creates A pathway from the observation to the acute as we saw in Teresa, which can occur either an episode day two or three depending on the condition.
36:03
And then ongoing manifestations despite observation can clearly be defined when that non responder criteria is met.
36:12
And that makes that defensible case to upgrade that patient to inpatient level of care.
36:19
And also proactive continue state reviews will facilitate timely and safe, safe discharges because we also have responder criteria and our responder criteria are proxies for discharge screens so that when someone meets that responder criteria, that's a signal that they should be able to be discharged that day.
36:45
And now we can.
36:47
Now we can expedite, expedite and facilitate that process required for a safe discharge.
37:00
Now let's talk about how we can leverage automation to drive efficiency.
37:07
Interpol Auto Review is our solution that extracts clinical data from the EHR and then it matches it to the Intercol criteria to either partially or fully complete a medical necessity review.
37:35
So this automation drives value throughout the process during primary review and then also throughout the whole process of secondary and peer-to-peer discussions.
37:52
So this is an example of what Interpol Auto Review looks like in the in the Intercol review window.
38:01
So this looks like Intercol, but it's Intercol auto review because it has folders.
38:07
So when a case is partially met, you can open this folder to see what the data is.
38:15
So for instance, here in this this second one creatinine greater than 1.5 times baseline we're because intercall because auto review may not know what the baseline was, they can't we can't fully complete that one, but we can give you the information to make it a one click very easy.
38:35
And here we do have the actual value and you can compare that to the baseline.
38:40
There are some instances as well where if the criteria is fully met, then we'll be able to fully complete and fully click that criteria point.
38:51
Perhaps maybe if the troponin was upper limit of normal.
38:55
In this case, it most likely wasn't because if you click on this, it would give you the actual troponin value.
39:07
How does this help reduce physician review, physician review burden?
39:14
There's a couple of ways that this works, but the bottom line is that we have this filter and funnel set up here.
39:23
So when we put these filters in place, the first filter being inter call auto review.
39:30
What it does is it takes all the cases and then the ones that that meets to a level of care are filtered through and then it's very easy for the secondary or for the primary reviewer to complete those cases with one or two clicks.
39:50
So now we have a reduction there.
39:54
And then those that those that can't be met those we can further reduce those by looking at the ones that may be straightforward.
40:05
So we can actually train your UL nurse lead.
40:09
Through ours, through some of our certified certification programs to be able to reliably recognize those straightforward cases so that they can prioritize which ones should go for physician review.
40:26
And then now we have filtered down to only sending those complex cases for physician review and that allows the physicians to focus where their expertise matters the most.
40:40
So this better filtering through automation as well as triage is gives a great impact on reducing that burden for on the physicians so that they can so that they can perform more thoughtful and make more thoughtful decisions.
41:02
This review summary might look familiar.
41:04
You saw it before with our with our non automated intercall.
41:09
But here with with intercall, we also we it includes those folders with the data.
41:18
So instead of having to manually put the values, they come, they come in as footnotes at the bottom.
41:27
So all the relevant data and the criteria guidelines are in one location.
41:32
So this can be used this, this can be used in writing decision rationale statements.
41:38
It can be used also during peer-to-peer conversations.
41:43
And then also it's also eliminates errors because now we don't have to worry about transcription errors because the information is is directly extracted from the EHR.
42:01
Some of you may not realize, but not only is Interqual a product, but it also comes, it has a host of services available and one of them is data and analytics.
42:12
So we have a data and analytics team that can partner with you to give custom and insights so that you can identify some trends.
42:22
You may want to identify reviewer trends.
42:26
You may want to identify which diagnosis are your greatest have the highest denial rates for you, or you may want to look at which which level of care is giving you the highest denial rate for instance.
42:43
And these these help you to proactively uncover and address concerning patterns.
42:51
So we do invite you to reach out to us so that we can assist you with this, with these efforts.
43:01
Another tool we offer is inter rater reliability, which is as I said before, the extent to which separate reviewers come to a similar conclusion regarding how medical necessity review criteria is applied.
43:17
So we have this available for nurses as well as physicians.
43:22
It's a web-based assessment application and it measures how well and how consistently an organization is applying intercall criteria.
43:32
So what's great about it is it measures staff competency.
43:36
It can identify knowledge gaps so that it can inform ongoing staff education.
43:43
It also makes sure that ensures that your organization is getting the most value from intercall criteria and those competition measures can be used to meet certification and accreditation standards such as your ACT and CQA and Joint Commission.
44:06
Focusing on the physicians, we also offer role based physician educations.
44:12
So we can we offer that to medical directors and physician advisors as well as admitting physicians so that they can help to understand the intent of our criteria, how to properly apply it, what documentation is required and then also best practices for consistently overlaying their clinical judgment so that we can make consistent determinations.
44:49
We also offer training for your end users, so physicians but also your other end users and this can be paired with the IRR testing pre imposed to measure impact.
45:02
So we have the Intercall Certified reviewer program, which is a foundational program and it supports the acute inpatient level of care reviewer to make sure again that they are applying the criteria consistently and to enhance their knowledge.
45:20
We have the Intercall certified instructor and that's our train to train the train the trainer program so that your organization can build its own internal education program, Intercal Certified expert resource.
45:34
That's the subject matter expert that go to person in the organization.
45:40
Maybe they would be the one to filter those cases before sending them for secondary review and can also address day-to-day questions from your team.
45:49
And last but not least, we have the Intercal certified physician, which is a very in depth physician education and it's an advanced physician reviewer program for the secondary reviewer.
46:06
So implementing these things for your team is how consistent changes in behaviors leading to outcome improvements will happen.
46:21
So let me close by reframing one key idea.
46:26
If secondary review volume in your organization keeps increasing, that's not a sound sign of a strong program.
46:35
It's a signal that something upstream is broken.
46:41
At its best, secondary review should be targeted, It should be intentional, and it should be high value.
46:49
It should not be a routine step that absorbs physicians time simply because the process did not support a better decision earlier.
46:59
The organizations that do this, well, they're not eliminating reviews, but they're improving the timing of them, the quality of the cases, and the discipline in which the cases are escalated.
47:13
And when all this comes together, everything improves.
47:16
We improve efficiency, consistency.
47:19
We improve physician satisfaction and ultimately patient care.
47:24
So if you remember only one thing from today, let it be this.
47:28
That secondary review should be a precision tool, not a volume problem.
47:35
And with that, I thank you for your attention and I'm looking forward to your questions and also and also following up with how this may apply to your organization.