Effective Medical Necessity & Clinical Reviews Amid the Nursing Shortage

Effective Medical Necessity & Clinical Reviews Amid the Nursing Shortage

The US is currently experiencing a significant nursing shortage, and it unfortunately isn’t expected to end anytime soon. Since the start of the COVID-19 pandemic, our country’s nurses have demonstrated their dedication and heroism, highlighted in countless news stories and social media movements. Nurses are critical to our healthcare system and comprise the most extensive portion of the health profession.

According to AHU, when hospitals and other healthcare facilities have an appropriate amount of nurses, patient safety, mortality rates, and overall patient outcomes improve. It’s estimated that adding 133,000 RNs to the workforce could save 5,900 lives and increase national productivity by $1.3 billion per year. Not to mention the estimated decline of non-life-threatening illnesses such as urinary tract infections, which are very common in hospitals, could decrease by 25%.

Unfortunately, staffing enough nurses to provide your patients quality care can seem impossible. Currently, 15 states have a cap on how many patients can be assigned to a single nurse or rely on internal committees to set appropriate staffing ratios. However, federal emergency waivers granted over the last couple of years now allow hospitals to work their nurses out of ratio, increasing caps and increasing undue strain on nursing staff.

The State of Nursing in the US

The nursing shortage is leading many healthcare providers to close units and scale back services, affecting high-acuity units like intensive care and emergency departments and long-term care like labor and delivery. While some hospitals are offering big sign-on bonuses and extra pay to attract and retain employees, many nurses are choosing to leave the profession or use their skills elsewhere, leaving healthcare providers and patients with significant gaps in care. These challenges quickly lead to other problems throughout a hospital or healthcare provider’s operations, including medical necessity and clinical reviews.

To manage these gaps in qualified medical necessity and clinical reviews, hospitals around the country are increasingly hiring case managers who are not registered nurses, leading to substantial increases in denials and lost revenue. Approximately one in five claims is denied due to coding errors, poor documentation, queries, and DRG downgrading, all of which can be closely tied to the reliance on caseworkers for medical necessity and clinical reviews.

1 in 5 claims are denied due to the reliance on caseworkers for medical necessity and clinical review

A Better Solution to Denial Management

One successful method of alleviating this situation is outsourcing medical necessity and clinical reviews to a third-party provider. With the right partner, medical necessity and clinical review outsourcing enables your clinical team to maintain an ideal nurse-to-patient ratio and uphold your commitments to high-quality patient care. Advent Health Partners takes a unique approach to payer reimbursements that helps providers decrease their denial rate without hiring additional nurses. How do we do it? Over the years, we’ve developed various strategies that lead to better overturn rates.

Advent’s clinically experienced team consists of a diverse group of registered nurses. Our registered nurses are subject matter experts in a variety of specialties including, but not limited to: 

  • NICU
  • PICU
  • Cardiology
  • Oncology
  • Wound Care
  • Neurosurgery 

Our nurses and their extensive clinical experience help us deliver a 90+% appeal overturn success rate for our clients. They have an in-depth knowledge of leading CDS tools like InterQual and Milliman Care Guidelines and train to keep current with ever-changing coding, billing, and government regulations to keep your procedures up-to-date and take a highly clinical approach to downgrades to ensure you recover maximum revenue on every claim.

By utilizing trained nurses to review all documentation and downgrades, we can recover more revenue faster for your organization.

Outsourcing with Advent

Advent’s reviewers are registered nurses with 20+ years of clinical experience who integrate seamlessly into your existing workflow, acting as an extension of your team to reduce administrative burdens across your operations and processes. Our reviews are first-level utilization reviews performed in real-time through EMR access. In the unlikely event of a denial, we’re committed to defending our work throughout the life of the claim at no additional cost. At Advent, our goal is to provide your team with the comprehensive support, knowledge, and resources to reduce denials and ensure you receive appropriate reimbursement.

Our team can provide your organization with data-driven strategies and leverage our business intelligence reporting software to improve your revenue cycle. We have experience identifying trends and employing solutions with the highest potential reimbursements and quickest timelines. Our Revenue Integrity Consulting team identifies root cause trends for your organization’s denials and delivers actionable recommendations. We offer a collaborative process, further education, modular implementation, and immediate bandwidth to support your team and processes.

Get in touch to learn more about how we can help you support your organization’s medical necessity and clinical review processes, reducing the administrative burden on your clinical team and reducing your time to revenue.

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