Utilization management sits between clinical care and the revenue cycle, and at most health systems it is still largely manual: status determinations, concurrent authorizations sent by fax, appeals that drag on for 60 to 90 days.
Sharon Kelley — former chair of revenue cycle at Rochester, Minn.-based Mayo Clinic, former CFO of Mayo Clinic Health System, and now of Kelley Advisory Group — said she’s seen the cost firsthand. “You have the clinical on one side siloed with the financial on the other side,” she said.
In a featured session sponsored by Xsolis at Becker’s 11th Annual IT + Revenue Cycle Conference: The Future of AI & Digital Health on Sept. 14, four leaders discussed what happens when utilization teams can see a patient’s whole clinical picture as it evolves. The panelists were:
- Sharon Kelley (moderator), founder and principal at Kelley Advisory Group LLC
- Heather Bassett, MD, chief medical officer at Xsolis
- Barbara Long, director of utilization management at Kettering (Ohio) Health
- Kim Sinclair, system vice president of integrated care management at PeaceHealth (Vancouver, Wash.)
Xsolis, founded in 2013, offers an AI platform that pulls real-time clinical data from the EHR to support utilization review and physician advisor workflows; the company says it works with about 650 hospitals. Two of its clients — Kettering Health, an eight-hospital system in the Dayton, Ohio, area, and PeaceHealth, a nine-hospital Catholic system across Washington, Oregon and Alaska — joined Xsolis’ chief medical officer to describe what changed after implementing it.
Below are four takeaways from the discussion.
Note: Quotes have been edited for length and clarity.
1. Before automation, utilization review teams were working blind.
Both systems described UM operating separate from clinical operations. At PeaceHealth, Ms. Sinclair said UM had been outsourced after the COVID-19 pandemic and ran on a criteria checklist in parallel to clinical teams, producing status mismatches, lost revenue and a loss of trust with clinicians. “We were really blind,” she said. “We didn’t have the data to help us understand how our payer partners were behaving in real time.”
At Kettering Health, which separated UM from case management in 2017, Ms. Long said nurses worked out of EHR queues with no reliable way to tell which patients needed attention first.
2. A continuously updating clinical score reprioritizes the work list.
Dr. Bassett described the Care Level Score™ at the center of Xsolis’ platform: it pulls real-time EHR data — comorbidities, age, labs, vitals, medications and documentation — into one predictive output ranging from 0 to 157. Above 75 indicates a higher likelihood of inpatient status; below 75, outpatient or observation. It updates as a patient’s condition changes. “It’s your personal assistant working 24/7 in the background,” she said.
Ms. Long said the filters flag status conflicts, such as a score above 75 on a patient in observation, so her team can cover more patients and send concurrent reviews proactively. “It’s really helped my nurses work to a higher level of their licensure and not just sit around and try to check boxes,” she said.
3. Reporting turned UM into a payer-accountability tool.
Ms. Long said her team now reaches about 95% of admissions within the first 24 hours and sends concurrent reviews every 72 hours instead of waiting for payers to request them. Kettering’s observation rate, once around 25%, is holding near 17%, and the efficiency gains let a couple of retirements go unfilled. Two reports matter most to her: a pre-bill denial comparison by payer, which she uses to press payers whose denials are frequently overturned, and an exception report flagging patients who stayed two midnights but were discharged in observation.
Ms. Sinclair said the monthly exception report now sits in PeaceHealth’s clinical throughput dashboard. “It’s a communication tool, it’s a storyteller,” she said. “It’s a way to really frame where the value is.”
4. Shared scoring can lower friction with payers directly.
Because the score is granular rather than binary, Dr. Bassett said, providers and payers can agree in advance on a threshold above which a case will be paid without dispute. Ms. Sinclair described an early collaboration with Humana at PeaceHealth, aimed at the cases most often reversed on appeal. Dr. Bassett said denials should be read in context: “Denials aren’t a bad thing. They’re something you have to manage in this process.”
What it means for revenue cycle leaders
The through-line was less the model than what it frees clinicians to do. PeaceHealth hired its new UM nurses for mindset rather than UM experience — from the ED, ICU, med-surg, periop and neurology — because the holistic view of the patient means “you no longer really need that kind of expertise. You need clinicians,” Ms. Sinclair said. Both PeaceHealth and Kettering now put UM reporting in front of CFOs and chief nursing officers to identify opportunities for improvement and drive continued results.
