Written By Jonna Mayfield, Senior Manager of Care Management, McBee
Since the pandemic, healthcare systems across the continuum have been grappling with severe staffing shortages. The Health Resources and Services Administration (HRSA) projects a nursing shortage of 78,610 full-time equivalent registered nurses (RNs) by 2025, with some improvement expected by 2035. Care management has not been exempted from these workforce challenges, as hospitals struggle to retain experienced professionals and maintain a balanced mix of seasoned and new staff. These staffing gaps have led to lost revenue from missed inpatient admissions and increased observation status cases requiring appeals.
Utilization management (UM) has faced significant challenges nationwide. Utilization review is a specialized field that requires expertise in aligning a patient’s clinical condition with evidence-based criteria to support medical necessity. However, staffing shortages have made it difficult for hospitals to adequately cover all patient units. As a result, many organizations are filling positions with less experienced nurses who may lack the necessary training. This has negatively impacted the quality and oversight of reviews, leading to inconsistent application of evidence-based criteria, increased payer denials and revenue loss. A well-structured utilization review process is important for determining appropriate patient admission status from the outset and for successfully navigating appeals. An effective UM program verifies that patients receive the right care in the right setting, supporting cost-effective healthcare delivery.
The Centers for Medicare & Medicaid Services (CMS) mandates that any hospital receiving Medicare or Medicaid reimbursement must have a utilization review plan in place to assess medical necessity. Despite this requirement, many hospitals lack the expertise to implement a best-practice, comprehensive model and to train their staff sufficiently. To ensure optimal outcomes, concurrent utilization review should be conducted for all medical admissions. Cases that fail to meet evidence-based criteria should be referred to a physician advisor. Every step of the review process should be documented to maintain consistency and strengthen appeals against medical necessity denials.
As reimbursement rates decline, the role of UM has become even more critical. A comprehensive UM program helps patients receive appropriate care while supporting organizations in optimizing revenue, reducing denials and lowering readmission rates.
Need Help?
Ensuring that staff have the necessary resources and support to effectively manage utilization review is essential, especially as hospitals face increasing financial pressures. While some organizations have the capacity to follow best-practice models, others may struggle to do so. Partnering with a trusted expert like the McBee Care Management team can help hospitals redeploy their valuable clinical resources efficiently. Our experienced RNs specialize in remote utilization review, facilitating appropriate level of care placement for optimal reimbursement.
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About the Author
Jonna Mayfield, Senior Manager of Care Management
Jonna has been a registered nurse for 33 years and specializes in care management for the last 12 years. She currently leads a large group of experienced utilization review nurses in supporting hospital admissions and continued stays with medical necessity criteria and evaluating the level of care and efficiency of the health care services being provided. Her team is able to provide high-quality UR staffing support, as well as process improvement in care management, for multiple hospitals across the country, leading to a decrease in denials and an increase in hospital revenue.
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