Photo from Unsplash

Originally Posted On: https://www.xsolis.com/blog/ai-driven-utilization-management-solution

 

‘Real-time, predictive analytics are essential’ for healthcare to tackle revenue and staffing challenges

Utilization management (UM, also called utilization review or UR) is a crucial part of modern healthcare operations. Controlling healthcare spending while ensuring access to relevant health services is in the best interests of patients, providers, and payers alike.

However, UM is also a major source of disagreements and conflicts between providers and payers. Additionally, manual UM processes require significant time and attention from staff. These resource-intensive workflows lead to operational inefficiencies.

XSOLIS is excited to share the results of a study from Chilmark Research, “Next-Generation Utilization Management (UM) Through AI.” With an exclusive focus on research and advisory services for the health IT solutions market, Chilmark is uniquely positioned to examine the issues surrounding UM and the technology solutions used to transform it.

Chilmark’s utilization management case study with a national health plan found that XSOLIS’ CORTEX® and Precision UM solutions resulted in significant time savings – automating functions while linking payers and providers in a manner that builds trust and reduces friction between the two stakeholders. The crucial underlying factor is eliminating subjectivity in patient status determination.

XSOLIS solutions harness the power of predictive analytics, AI, and automation to streamline the UM process. Here’s just one example of specific findings from the study: Using CORTEX to conduct clinical reviews rendered a determination 38% more quickly than fax, and 15% more quickly than through their EMR.

We’ll review more results from the study later on, along with examining the unique qualities that make CORTEX so valuable for streamlining and optimizing UM. First, let’s take a closer look at the current state of UM for payers and providers.

Utilization Management: The Current State of Affairs

For payers and providers, utilization management is vital for both parties to align on the medical necessity and overall suitability of the procedures and care provided to patients. UM helps to manage costs and connect patients with appropriate and relevant treatment and services. With efficient workflows and oversight in place, UM can benefit all stakeholders.

Unfortunately, UM can also be a cause of administrative delays, friction between payers and providers, and other burdens caused by siloed views of outdated data and the general lack of transparency. Misalignment on medical necessity is often followed by complex and expensive claims reviews.

Recent studies outline the severity and urgency with which we should embrace better technology solutions to help reform unnecessary, costly areas within healthcare:

• Of the nearly $4 trillion dollars spent annually on healthcare in the U.S., one-quarter of that spend has been identified as non-clinical administrative functions, which should be prioritized for reform.
• A McKinsey & Company study further recommends that there is a $15 billion dollar opportunity to eliminate waste associated with medical necessity, required documentation and payer-provider communications.

Utilization management emerges as an underserved area that is ripe for reform, because its traditional technological solutions are “in need of modernization for the demands of today’s healthcare systems,” according to Chilmark. Manual and criteria-based UM processes tend to require too much time and effort from staff on both sides of this relationship. Outdated UM workflows then create inefficiencies and drive wedges between stakeholders.

Hospitals and health systems are still adapting to staffing challenges created by the COVID-19 pandemic and its after-effects. U.S. News & World Report explains that steadily increasing demand for registered nurses, along with a decrease in the total number of employed RNs, has created a widespread nurse shortage.

The pandemic made the healthcare industry recognize a variety of operational inefficiencies. In this leaner healthcare environment, efficiency is crucial. UM that relies on time- and labor-intensive processes is the opposite of what today’s payers and providers need.

The good news is that transformative UM solutions are available to payers and providers. XSOLIS’ cutting-edge solution, CORTEX®, combines artificial intelligence, machine learning, and predictive analytics to streamline the UM process. That leads to major benefits like time savings and more efficient allocation of resources.

See XSOLIS’ vision for major improvements in payer-provider collaboration by creating a single source of truth and shared understanding. Watch Payer-Provider Relationship: A New Future.

How Modern Technology can Transform UM

A utilization management program, and related functions like prior authorization, are only as efficient as the processes and tools that support and underpin them.

Access to data (or the lack thereof) represents a major opportunity (and challenge) in terms of UM. The Chilmark time study explains: “Historically the UM process has been fraught with tensions between payers and providers, due to contested outcomes of the process, different data sources, missing or incomplete documentation from the clinical record, and frameworks that can be used in the review process.”

Ensuring that both payers and providers can access complete, relevant, and up-to-date information is crucial.

However, common pathways for sharing data, like faxes and EMR access, only deliver general-purpose information captured at a fixed point in time. That limits the effectiveness of the data in the decision-making process. It can lead to extended back-and-forth conversations and other delays.

Modern technology can help to resolve this issue. Tools designed specifically for UM collaboration, like CORTEX, offer easily accessible, relevant, and current information to all stakeholders. Providing data and analysis from a UM-specific viewpoint helps to put payer and provider teams on the same page, reducing friction and emphasizing collaboration.

Learn more about the advantages offered by CORTEX in Chilmark’s payer time study.

The Importance of the Care Level Score in CORTEX: Automated Determinations and Time Savings

Even though UM is a complex process – the complexity of which can lead to delays in decision-making and friction between payers and providers – there are also many potential areas of improvement to consider.

One especially time-consuming task for payers and providers is aligning on patient status determinations.

“XSOLIS’ technology is purpose-built to address the pain points that payers and providers encounter during the utilization management process,” said Joan Butters, CEO and co-founder of XSOLIS. “The results of the Chilmark Research white paper and time study unequivocally show the benefits of integrating an AI-driven platform into UM workflows for increased staff efficiency and improved alignment across payer and providers.”

Ensuring that patients, or members, receive the right services at the right place and time and cost is crucial for effective healthcare. That’s true from a financial perspective as well as when considering the best interests of the patient.

XSOLIS’ proprietary Care Level Score (CLS) is a cornerstone of CORTEX. It brings together everything from vital signs and lab results to physician’s notes, medications, and other clinically relevant data. A set of purpose-built, advanced algorithms continually calculates a CLS for each patient ranging from 0 (a clear case for observation status) to 157 (an obvious need for inpatient status).

The granular nature of the CLS plays a major role in its effectiveness. When payers and providers agree on thresholds and commit to using the CLS to determine each patient’s status, they can further benefit from Precision UM — automating approvals for obvious inpatient determinations through CORTEX instead of having to work through each case manually.

This additional benefit of automation delivers significant time savings. Chilmark’s utilization management time study found that CORTEX coupled with automated review processes offers:

• Time savings of as much as 83.3%, when compared to using faxes for review. Time savings when compared to traditional EMR workflows was 76%.
• First-touch determinations were reached 66% of the time. That’s an improvement of 36% when compared to traditional EMR access.

These results indicate a substantial amount of time back in the days of busy staff for both payers and providers.

Using a set of specialized algorithms to find the correct patient status has many other benefits as well. It eliminates the potential for wasted time and human error, as well as delays that leave one or both sides waiting for information or clarification. There’s one more major advantage to consider as well, which takes clinical efficiency to another level considering the industry’s staffing challenges.

Empowering Clinical Staff to Provide the Most Value

When clinicians don’t need to spend valuable time making status determinations for obvious cases, they can focus their knowledge and experience where it’s needed most.

Instead of spending time on cases that can be capably determined by algorithms, clinicians can focus on more revenue-sensitive cases. By taking a deeper dive into the relevant data and associated narrative and applying their expertise, clinicians can use some of the time savings offered by AI and algorithms to support better patient outcomes in complex cases.

Focusing on this type of work, instead of administrative tasks, means clinicians can deliver additional value to their hospital or health system — and likely feel more satisfied with their daily duties as well. XSOLIS customers often describe the real-time data insights as similar to “having their own personal assistant.”

Realizing Sustainable Utilization Management Improvements With Modern Technology

 

Chilmark’s report includes key data from a national health plan time study. The results, as detailed above, highlight major improvements when the CORTEX platform is used in conjunction with Precision UM automation capabilities.

UM is an area of the healthcare industry that has long been underserved by technological advances. That lack of development meant UM was made up of manual, time-consuming processes. And those processes led to friction between payers and providers.

With CORTEX and Precision UM in place, automation takes on important but time-consuming and rote tasks, empowering staff to focus their attention where it’s needed most. As Chilmark reiterates, such “real-time predictive analytics are essential in the era of value-based care.” A connected network of payers and providers will not only find shared value in time savings as noted in the study, but most importantly, they will be better positioned for a new path forward – one where improved communication and collaboration are not only possible, but attainable.

To read the full Chilmark Research white paper, click here