The Utilization Review (UR) function in the emergency department (ED) serves as a critical component to ensure whether a patient is placed as inpatient or observation. Establishing the UR team to manage patient status at the point of admission is imperative to minimizing denials down the line. Too often, hospitals waste time and money by overlooking the need for hiring nurses that are trained and dedicated to UR, leading patients to be incorrectly placed and ultimately denied for those claims.
An example of this common challenge was a large health care system in the Mid-West, encompassing nine hospitals and a provider network of over 3,000 physicians, needing to address an inefficient utilization process as a result of a recent merger with another major health system. This merger subsequently led to inconsistent processes, systems, expectations, goals and key performance indicators (KPIs). The health system incurred an average of almost $500,000 per month in denials and an unusually high observation rate (29%) after the merger. The utilization process was not effective because the staff available were not proficient in UR and care management guidelines, and they did not hire enough staff to manage the 
process. As a result of these challenges, there were disparate processes across departments.
To get the utilization review process under control, the health system hired a team of UR nurses and consultants for six months to address the critical utilization gaps. The firm implemented several measures to significantly improve the utilization management in the ED. Some of those steps included providing departmental assessments to identify staff competency, process consistency, and UR tools, and real-time coaching of the physicians on the quality and completeness of documentation and fostering significantly better understanding of criteria.
Read more to find out all the steps taken by the consulting firm to address the utilization review challenges and recovered $1.8M in revenue for the health system.
