While this process is an expense for organizations, it can ensure they are billing payers correctly and receiving proper reimbursement.
During a webinar hosted by Becker’s Hospital Review and sponsored by Optum360, presenters shared four key pillars of an effective utilization review program.
Presenters were:
- Kurt Hopfensperger, MD, regional vice president of provider relations and education for Optum360
- Tabitha Hapeman, RN, MSN, manager, resource management center; manager, patient financial services; revenue management department at Norfolk, Va.-based Sentara Healthcare
The pillars:
1. Proper tools. Effective utilization review requires proper tools, such as artificial intelligence or an evidenced-based medicine research database, according to the presenters. Ms. Hapeman said this software can help registered nurses in utilization review know where to document and how to communicate with payers. Dr. Hopfensperger noted another benefit as well. He said: “UR is a difficult process. It’s dealing with enormous amounts of information from medical records. [However, artificial intelligence can] parse records, find clinical details and link details with evidence-based medicine.”
2. Contracting support/knowledge. Payer behavior and the understanding of their behavior is also viewed as important. If organizations have dedicated RNs in utilization review who can track payer behavior trends, and report those to leadership, then leadership can take those insights to the contracting department, said Ms. Hapeman. Initially, there may not be anything the contracting department can do as far as support, she said, but there will be time when that contract can be renegotiated. Language related to claim denials can be addressed at that time.
3. Physician engagement. Physicians play a key role in utilization review through their documentation of care. Therefore, Ms. Hapeman recommends hospitals and health systems adopt good physician engagement and physician education practices to help physicians understand how to tell a patient’s care journey story in a way that will lead to proper reimbursement from payers.
4. Compliance-based process. At any hospital or health system, leadership must build and sustain a utilization review process that is compliant with federal guidelines. And Ms. Hapeman noted doing so requires routine reassessment. “It’s not a process you can build, implement and forget about. You have to build it, maintain it and constantly reassess it,” she said. She especially recommended reassessment from October through February when payer contracts change, and CMS often updates guidelines.
Learn more about Optum360 here. Listen to the webinar recording here.
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