A health plan is reviewing a medical necessity claim for a 50-year-old male with a neurostimulator placed for pain control related to chronic back pain and right lower extremity numbness. He is a former police officer injured while on duty with nine subsequent back surgeries resulting in post-laminectomy pain syndrome. He now requires a cane to walk and wears a brace on his right leg due to the periodic loss of balance caused by the numbness.
This payer needed a way to reduce the time it took to review the 367-page medical record. They also needed to be able to verify the guidelines for a high-dollar (>$20,000) procedure and make sure that five specific criteria points were met per the patient’s policy.
- Criteria #1: Physical Exam and Psychological Exam were performed pre-operatively; the patient was cleared for surgery from a psychological standpoint.
- Criteria #2: There are no untreated existing drug addiction problems.
- Criteria #3: More conservative methods of pain management were tried and failed.
- Criteria #4: There is documented pathology (objective data) that explains the reason for the patient’s pain.
- Criteria #5: There was a significant reduction in pain (50% or more) with a 3 – 7 day trial of percutaneous spinal stimulation.
CAVO was able to perform a three-step verification process in seconds:
- Step 1: Surgical Procedure Verification
- Search for “operative report,” which renders this report the first result. Verification of the surgery end time was found on page 154.
- Step 2: Criteria Verification
- Search for “consultation” to find the pre-op physical exam (versus post-op). The record contains a pathology for the patient’s pain, supporting Criteria #4. Criteria #3 for trying more conservative pain management methods is answered on the same page of this report. Above this paragraph, the record states that the patient underwent a trial for six days with a 75-80% improvement, which satisfies Criteria #5.
- Step 3: Criteria Reassessment
- A search for “psych” returns all of the consult notes, and after reading, it’s noted there is no mention of being cleared by psych for this surgery. While Criteria #2 still needs to be verified, there is no need to continue reviewing this case, as all criteria must have been satisfied pre-operatively.
Conventional medical necessity reviews demand labor-intensive efforts involving manual indexing of medical records, worksheet creation, and comprehensive reading of each note for determination. In the case of this specific record’s review, that equates to an estimated 160 minutes of labor.
CAVO technology was able to perform the same workflow, using its built-in AI capabilities, in approximately 50 minutes.
That equates to a time savings of nearly two hours or a 320% increase in productivity.
By harnessing advanced search logic and automated data extraction, CAVO expedited the evaluation of complex patient cases. In this scenario, its efficient approach not only led to a definitive determination but also demonstrated significant time savings and increased productivity.
CAVO supports various complex clinical claims review processes performed by health plans and services companies.
CAVO empowers skilled clinical and coding resources with AI-driven functionality that shifts the focus from “low value” tasks and requirements such as document access, search, analysis, and determination support within medical records and other unstructured data to “high value” tasks and requirements such as validation of predictive determination.
The technology enables clinical and coding resources to easily access and structure medical records, itemized bills, and additional clinical data efficiently, consistently, cost-effectively, and profitably and delivers the information in multiple intuitive interfaces to support dozens of use cases.