With the majority of Americans now enrolled in privately or publicly funded health plans that use utilization management (UM) programs as a primary cost-containment strategy, it has never been more important for hospitals to follow a process that is clinically sound and routing patients accurately/efficiently than now. Becker’s highlights utilization review as a key component of leveraging case management best practices with the revenue cycle, which paves the way for improved workflows.
Decisions about a patient’s care that were once decided solely by doctor and patient are now being evaluated by external reviewers such as an employer, insurer, HMO, or any third party responsible for most of the cost of care.
Where the care will occur, by whom, and in some cases, the treatment itself is being dictated in large part by these third-party entities. Provider utilization management becomes key when answering two important questions:
- How do we ensure the patient receives the correct treatment by the correct provider ( i.e. nurse, doctor), where as to spend accurately without compromising care?
- How do we flag and stop unnecessary or wrong treatments and medical services without endangering the patient?
All in all, the goal is to better assign the right people to the tasks up front, so providers are able to capture more revenue.
Unfortunately, there are no instant fixes -- but there is a way to improve through experience.
Through ‘Big Data’ or Machine Learning, we gain knowledge over time that allows our technological systems to constantly be reinventing themselves and re-learning. Each interaction is another data point that paves the way for a future correct decision.
There are a number of different ways to use machine learning to better improve provider utilization management and financial performance. In some cases, that might mean developing or implementing new tools to better utilize the data you already have. For example, if you can collect and aggregate your data points through technology, you may be able to make better predictions on future admissions. This allows the allocation of resources to be done in a more productive and fiscally responsible manner, and also better meet patient needs.
We’re excited to be at the forefront of this rapidly developing area of focus. Through the use of Advent’s clinical experts and technology, recommendations can be made to better optimize workflows -- pulling information faster, and helping healthcare providers make the "right" decisions upon patient intake and assign the right employee to tasks. The end result: Maximizing revenue and working more efficiently, with less to review in the future.
Healthcare providers who partner with an Advent clinical review expert can see improved utilization review processes and improve workflows --