Explore Utilization Management for Payers
Learning Objectives
After completing this unit, you’ll be able to:
- Describe the key users of utilization management for payer organizations.
- Describe how Utilization Management for Health Cloud provides solutions for payer organizations.
Utilization Management for Payers
With Utilization Management for Health Cloud, payers can:
- Deflect call volume and reduce administrative burden by setting up rule-based need assessment and auto-approval of authorization requests
- Automate intake of PA requests received through asynchronous channels such as fax and direct mail
- Enable member 360-degree view with links to benefits coverage and historical pre-authorization requests
- Collaborate seamlessly with authorization coordinators for quicker decisions
- Gain insights to support clinical review decisioning and operational improvement
- Improve provider and member satisfaction
Charles Green is still in search of treatment for his chronic hip pain. Although his in-network orthopedist recommends physical therapy as the initial approach, he opts to seek hip surgery at an out-of-network clinic that is known for aggressive treatment. After an initial screening, the hospital collects all the required documents and faxes them to his insurer, Cumulus Health Plans, for authorization.
Utilization Management for Health Cloud helps payers effectively manage and resolve complex cases like this one. Here’s how.
Intake Management
Intake management involves the processing and routing of authorization requests to the appropriate review resource. At Cumulus, Sam Bennett, an intake specialist at the contact center, handles these key tasks.
In her role, Sam:
- Addresses queries and provides guidance on PA requirements
- Processes offline authorization requests
- Checks member eligibility and benefits
- Conducts administrative review of requests
- Approves requests based on pre-established criteria
For offline authorizations like Charles’s faxed surgical request, Sam uses Intelligent Document Automation tools to simplify the intake process. Using action plan templates, she attaches the scanned document to document checklists, assigns it to the appropriate document queue, and manages it all in a single document workspace.
Sam uses Intelligent Form Reader, powered by Amazon Textract, to automatically extract data from the requests. This intelligent technology seamlessly integrates the data with the appropriate Salesforce records.
By leveraging intelligence and automation, Sam's workload is significantly reduced. Now she can concentrate on reviewing and channeling requests more efficiently.
Sam incorporates all of the faxed information into a record that she uses to help create the PA request.
Alternatively, the authorization coordinator can create an authorization request manually by calling the provider’s office, collecting the needed information, and entering the data into a guided flow.
Sam initiates the request and selects Inpatient Physical Health Review as the authorization request type.
Next, she checks if this particular service request needs PA.
The hip surgery indeed requires PA, and Sam proceeds to provide additional details. After submitting all the needed information, she reviews the request.
Next, Sam receives confirmation that the request is submitted and is now in administrative review.
Behind the scenes, the guided flow generates new records for the care request, care request item, and case. The case record is customized to display all the utilization management stages.
After verifying all the information and documents for the request, Sam moves the care request to the next stage, UM Nurse Review. OmniChannel routing rules ensure that the request is directed to the appropriate clinical resource for review. In this case the resource is a UM nurse who specializes in surgical requests.
Clinical Review
After the administrative review of the request is complete, it’s time for a more comprehensive clinical review. The clinical review process typically starts with the UM nurse.
In their role, the UM nurse:
- Conducts clinical reviews of PA requests aligned to evidence-based and payer-specific guidelines
- Keeps track of service-level-agreements (SLAs) and follows up with the medical director to ensure urgent requests are prioritized
- Follows up on additional requirements
- Coordinates with the provider for decision communication and scheduling peer-to-peer review
Thanks to Health Cloud’s Utilization Management app, Cumulus UM nurse, Eliza Sherwood, has all the necessary tools to review the request.
Eliza examines her dashboard, which presents a visual overview of her assigned cases and their statuses.
From the dashboard, Eliza opens Charles’s surgical care request case, where she can view all key information about his request.
The case record also leverages intelligent tools that provide users with predictive metrics to assist them across the UM lifecycle.
SLA Breach Likelihood Prediction is an AI based model that predicts the likelihood of a service-level agreement (SLA) breach based on the specific characteristics of the authorization request. Payers can use these predictions to review top factors that cause delays and ensure SLA-compliance by acting on them.
This component can also display milestones so the UM nurse and other key users can stay on track.
For Charles’s surgical request, there is only a minimal chance of an SLA breach based on the level of care, admission source, and other factors. Eliza, though, must complete her review very soon to keep things on track.
Approval Rate is an analytics-based card that provides the overall approval rate for the requesting provider and a service approval rate for each specific service requested.
For Charles’s surgical request, the out-of-network physician infamously known for aggressive treatment has a PA approval rate of only 33%, which is much lower than the global approval average. And the approval rate for this specific hip procedure is even lower, with an approval rate of only 14%.
Additionally, users can customize a Services Pathway Recommendation dashboard, which uses an AI-based model to recommend the likely services needed based on the member’s diagnosis.
The pathway identifies three additional services that typically accompany Charles’s primary diagnosis. Users can adjust the likelihood threshold to surface more or fewer services.
Payers can then use this information to set up workflows for clinical auto-approval to further automate the process.
Eliza next launches a prebuilt UM Nurse Review guided flow right from the case record.
All previous details related to the request automatically populate, saving her time and effort.
Eliza also refers to evidence-based clinical review guidelines to establish the medical necessity of the care request. Health Cloud provides integrations with industry leaders such as MCG and Interqual.
Eliza seamlessly reviews the medical necessity criteria for Charles’s surgery request.
Based on these guidelines, Eliza determines that Charles's request doesn’t meet medical necessity criteria.
She submits the decision, which instantly routes the request to the Medical Director, Dr. Peterson, for final review.
Decision and Communication
While the UM nurse can approve decisions, she typically can’t deny a request. That responsibility rests with the medical director.
In her role as Medical Director, Dr. Peterson:
- Reviews assigned PA requests against medical guidelines
- Flags requests for peer-to-peer review
- Provides final approval or denial decision with reasons and references
Dr. Peterson performs her final review with the help of a prebuilt medical director guided flow.
After reviewing all the information, she ultimately denies the request for a lack of medical necessity as there is no evidence of conservative treatment.
The guided flow allows Dr. Peterson to easily select the clinical details and verbiage to include in the denial letter.
After Dr. Peterson completes the review, Charles promptly receives a notification informing him of the denial. If he wishes, Charles has the option to initiate an appeals process, which Cumulus has also set up using Health Cloud. However, Charles decides to give the approved physical therapy sessions a try.
To his surprise, Charles responds exceptionally well to the sessions and experiences a significant reduction in his hip pain. He is delighted to have avoided surgery and can now enjoy a life free from pain for the first time in years.
Thanks to Utilization Management for Health Cloud, payers like Cumulus can ensure that its members consistently receive the right care, at the right time, and in the right setting.