What is a health system without patients, or patients without a health system? Patient satisfaction is overwhelmingly important to the growth and success of a health system, and in turn, they expect the utmost care. That doesn’t mean the system is without its complications.
Utilization management is designed to increase patient satisfaction while improving a hospital or health system’s bottom line. Below, we discuss two major factors that decrease patient satisfaction and how utilization management works to combat them.
High Healthcare Costs
Healthcare costs, like so many other things, have been increasing over the years and are projected to continue rising. In addition to healthcare services, medication costs are steadily rising, surpassing the inflation rate. All of these increases are being felt by patients. Healthcare, a necessity, can start to feel more like a luxury.
Utilization Management is crucial to fight the ever-rising cost of healthcare. One of the main goals of UM is to lower health costs by ensuring all procedures are medically necessary and efficient. This clarification is mutually beneficial to health plans, healthcare providers, and patients. Health plans win by only paying for legitimate, medically necessary claims. Health systems win by having a higher clean claim rate due to the medical necessity denials decreasing, and patients win by only receiving appropriate services and paying lower out-of-pocket costs.
UM Benefit Example:
Prior authorizations are utilization management’s first defense against high healthcare costs. Upon admittance to the hospital, a nurse will perform an initial review to determine the most logical course of action based on the patient’s health records and current conditions. The nurse may determine a care plan that differs slightly from the hospital’s protocols. The nurse might consult with the patient’s physicians to prove the medical necessity for a specific care plan.
This initial review is one of the main predictors of the cost to the patient later. An ICU versus a standard room carries a considerable price difference and sometimes might not be necessary. Regular checkups throughout the patient’s stay will help keep hospital staff on track with documentation and determine if the care plan is still suitable for the patient’s needs.
Right Care at the Right Time
1996 saw the dawn of the fee-for-service model in the American healthcare system. This model has been heavily criticized, citing the lack of accountability the model offers, hurting patients and driving up costs. The basis of this model was supposed to be an assurance that the health system gets paid for the services provided, but the reality is that patients rarely receive the care they require. ome patients get too much care and receive unnecessary testing, prescribed medication, and even procedures. More commonly, though, patients are underserved. Access to healthcare and unaffordable treatments are topping the list as reasons why some patients aren’t receiving care. Regardless of necessity, fee-for-service assigns a value to patients and services.
In the past several years, though, hospitals nationwide have attempted to lower healthcare costs by transitioning to a value-based care model. In this healthcare model, health systems are paid based on patient care outcomes, not services provided. This is a great way to ensure patients are getting the care they need and lowering the costs of that care.
UM Benefit Example:
One of the benefits of utilization review is assessing the appropriateness of procedures rendered. A nurse or claim expert will perform a retrospective review to ensure appropriate reimbursement and procedural suitability. Medical necessity accounted for approximately $2.5 billion in denials in 2022. In addition to higher patient satisfaction due to proper care and combating healthcare waste, utilization management also can increase an organization’s clean claim rate.
Future Encounters
Each patient is unique and deserving of quality care. The system has room for improvement, and there is ample learning opportunity within each encounter for hospital staff. Utilization management is a valuable tool for each specific patient encounter, and its value increases the longer the system is in place. For patients, the healthcare system can be scary. Health problems and the possibility of going into debt over these problems are huge burdens that utilization management is designed to ease.
How Advent Can Help
Advent Health Partners’ utilization review process uncovers opportunities to improve organizational management, eliminate oversight, and create systemic approaches to ensure maximum revenue recovery. Advent Health Partners works as part of your team to complete more utilization management reviews, reinforcing your organization’s denial prevention strategy and letting your clinical team do what they do best: patient care.
To discover how Advent Health Partners can increase financial recoveries and operational insights for your hospitals or health system, please connect via the button below.