Centralizing Utilization Review Functions is a cost-saving quality improvement measure, closes gap in coverage due to inter-rater reliability
Many organizations of all sizes are moving the Utilization Review (UR) function from a unit-based model to a centralized model. They are moving away from the ‘triad model’ where care management staff perform UR, case management, and discharge planning. Separating the UR function and having it report to both a clinical and financial structure allows for the realization of many benefits. Centralizing the UR function allows for economies and best practices to be realized.
In the triad model, nurses are often consumed with activities surrounding discharge planning and social work, leaving robust UR the last to be completed. By not completing UR on every patient, organizations increase the likelihood of denials and miss opportunities to convert observations to inpatient. Within a centralized model, UR is the primary focus.
Many forward-thinking organizations recognize the negative financial impact of inaccurate or non-existent UR. By initially identifying the appropriate patient status, denials are reduced, observation rate is more reflective of the care provided, length of stay is better managed and opportunity for additional revenue is identified.
This function needs clinical guidance and oftentimes a ‘dotted-line’ relationship exists with leadership in a clinical area for quality assurance purposes.
Administrative activities such as sending clinical, planning assignments and coverage, and responding to payer requests can be assisted by clerical staff in support of a leader. This is a cost-effective switch that reduces staffing needed, and the time it take to complete these tasks.
By not being unit-based, UR staff can cover multiple locations more easily. They can cross-cover for each other during absences or times of high census in a particular area. Staff can also be redeployed after completed an assignment if they still have time available on their shift– allowing organizations to be more productive with the same amount of resources.
Consistency & Quality
While organizations hope their staff are performing to the top of their license and conducting reviews in the same way, this isn’t always the case. By centralizing the UR function, management can communicate best processes, implement inter-rater reliability through training, and monitor productivity consistently across all UR staff with less effort.
Where has this worked?
A large health system that was created by the merger and acquisition of several individual facilities made the decision to centralize the UR function for their newly formed system. The UR staff were moved from a reporting relationship to care management department to one where they reported to the revenue cycle department. UR staff were brought to a central location and asked to perform UR remotely. Prior to this change, the health system was function on two legacy EMR systems and all UR staff performed their roles in different ways and had not been trained consistently.
By identifying the need for trained administrative support, the UR staff now had assistance with routine, non-clinical functions. The administrative staff were trained to retrieve and relay phone messages from payers, fax request for clinical information to payers via a systematized work-list function, and assist with the distribution of daily work assignments with help from department leadership.
Relieving the UR staff of these non-clinical functions, gave them more time to focus on performing reviews. They were trained consistently across all facilities and able to cover for each other during times of need. Department leadership could focus the UR resources to where the greatest need was.
UR staff were now allowed to cross-cover for each other, which led to department leadership implementing and training program where all nurses received inter-rater reliability training. Reviews were no being performed consistently–with no gaps in coverage–and the quality of them improved.