An Acute Utilization Management partnership that results in accurate patient status and increased revenue
The shift to value-based & patient-centered care has made it vitally important to ensure that your organization has an effective acute utilization management plan that can save you time wasted on inaccurate patient status and improve reimbursement.
Our acute utilization management services work directly with your case management program leaders, case management staff, revenue cycle team, and physicians to develop and implement a successful and robust utilization management workflow that supports the correct patient status at the time of admission. We conduct continued stay reviews to verify that the patient continues to meet medical necessity. These robust healthcare utilization reviews have helped hospitals and health systems improve care efforts throughout their organization, significantly reduce denials, and increase net revenue.
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During the pandemic when our health system faced workforce challenges, McBee Care Management & Utilization Review Services helped streamline our operations and supplement our workforce capacity for emergency department admission and pre-operative reviews. Within just two weeks, McBee seamlessly became an extension of our team and resolved critical gaps to help us ensure our patients receive the appropriate level of care in the right setting at the right time.
McBee has been our trusted partner for Utilization Management support. In the first year of partnership, McBee successfully improved our margin by over $7M and reduced denials by 17%. In addition, they provide insightful findings that have enabled our health system to improve our physician engagement and operational performance.
The McBee Advantage
Actively managing patient status at the point of admission is critical to ensure proper reimbursement, reduce the risk of a denial, and identify opportunities for conversion to inpatient status prior to the first midnight. Our hospital utilization review service team verifies that documentation meets (or supports) medical necessity requirements, utilizing hospitals’ approved evidence-based criteria and collaborating with the providers for any additional supporting documentation. Initially identifying accurate patient status results in reduced risk of denials, improved observation rates to be more reflective of the care provided, and actively managed length of stay, which results in additional revenue.
Paired with our operational assessment and executive reporting, we identify provider trends, improve physician order accuracy and responsiveness, and drive acute utilization management improvement throughout your organization.
Remote, real-time first-level utilization review coverage anytime: overnights, weekends, and holidays
Providing Emergency Department, inpatient, or ad hoc case review support options
Over 308,000 first-level reviews conducted by our clinical experts
Experienced registered nursing UM staff with an average of 15+ years of acute care experience
Expert application of industry standard criteria guidelines (InterQual® and MCG® Guidelines)
5,576
Total IP Conversions made in all clients
$27M
In additional revenue
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Decades of Industry Experience. Solutions that Empower.
Frequently Asked Questions About Acute Utilization Management
Acute utilization management is the process of reviewing and evaluating the medical necessity, appropriateness, and efficiency of healthcare services.
A review of your organization’s acute utilization identifies gaps in care and inefficiencies in processes, resulting in recommendations that help you better allocate resources so as to reduce wasted time and effort. McBee assisted an east coast children’s hospital (serving over 45,000 annual ER visits) by providing extended hospital utilization review care management coverage, particularly during weekends and after-hours, to address high denial rates. These efforts led to a $1.7 million increase in revenue within one year, representing a 4% rise in net patient revenue for the hospital. Read the full care management review case study.
By assigning the right care to patients at the right time and in the most appropriate setting, effective care utilization management leads to better patient outcomes and reduced lengths of stay. Financially, it helps minimize avoidable denials, optimize reimbursement, and reduce wasteful spending, thereby boosting revenue and operational efficiency.
A utilization review is a vital part of acute utilization management that helps identify opportunities to better align clinical decisions with payer criteria and care needs. McBee conducts reviews to help reduce improper care utilization, prevent claim denials, and enhance overall compliance. Organizations that integrate a rigorous acute utilization review process typically see fewer rejected claims, stronger reimbursement, and more efficient care delivery—all of which contribute to smoother revenue cycle recovery and improved financial performance. Read more about the benefits of McBee’s utilization reviews.
Within the first year of implementing reviews, health organizations often see tangible improvements in denial and observation rates, as well as net revenue. McBee focuses on implementing sustainable changes that yield both immediate and long-term financial benefits.
A quality review program refers to a structured process whereby utilization review cases are sampled and evaluated to ensure that clinical reviewers are applying standardized evidence‑based criteria consistently, choosing the correct criteria tools, and accurately following the workflow for admission/continued‑stay/denial decisions. Quality reviews are critical to mitigate human error and protect reimbursement and compliance.
Key components include:
- Annual inter‑rater reliability testing of each clinical reviewer to ensure they score above the minimum threshold of the criteria tool being used
- Monthly sampling of individual cases where documentation, criteria selection, application, and subsequent workflow actions are scored
- Feedback to reviewers on non‑passing cases, targeted education or correction, and increased review quota for reviewers under a certain passing threshold (for example < 95 %) to ensure rapid improvement
- Reporting of reviewer‑level and aggregate team quality scores to leadership and reviewers to monitor trends and support performance improvement
Beyond individual reviewer performance, aggregate quality data supports insights into team performance, workflow bottlenecks, documentation gaps, or tool‑application inconsistencies. With those insights leadership can:
- Adjust training and workflow design to reduce errors
- Monitor trend data (e.g., reviewer deviation rates, common error types)
- Strengthen revenue‑cycle outcomes (better reimbursement, fewer denials, fewer days of inappropriate stay)