An Innovative and Collaborative Approach to the Utilization Management Process Within An Integrated Care Delivery And Finance System (IDFS) Anita Carter BA, RN; Ann Kostial, RN, BS, MHA, ACM; Sally Erinc, MSN, MBS, RN; Susan Faight, MSN, RN, IQCI; Rhonda Martini, MSW, LCSW; Amy Kowinsky, RD, LDN; Jennifer Flaherty, BSN, MSN, RN
UPMC Introduction
Pittsburgh, Pennsylvania
Utilization Review Activities for UPMC Health Plan Patients
This new integrated delivery and finance system (IDFS) model seeks ways to reduce administrative costs by eliminating duplicative activities while reinvesting in processes that generate enhanced results in the future environment.
➢ Prior to implementation of the IDFS UM model, a duplicative review process for initial admission authorization reviews was identified as an opportunity for improvement and alignment between our provider and payer systems.
Methods A team was established of both payer and provider leaders with a goal to build a single review process for these cases. Over several months, new processes were designed, technology was integrated, and a new IDFS UM team of nurses from both the payer and provider sides was established.
0
Work Transitioned To The New Integrated Model ✓ Completing admission reviews for all patients insured by our payer in our acute care hospitals ✓ Reviewing observation cases daily and upgrading to inpatient if clinical condition changes
✓ Communicating with the acute care managers and physicians as needed
Results Average Hours to Complete Admission Review
➢ The purpose of the Utilization Management (UM) redesign was to develop a progressive operating model enabling our payer and provider systems to effectively and efficiently administer utilization management and related operating processes as a true IDFS.
Between January 2018—April 2018: ✓ The IDFS single review process was implemented with a phased-in approach for the hospitals. ✓ All UM activities for patients bedded as either acute inpatient, observation, or extended recovery were transitioned from the provider UM team to the payer UM team thereby creating a single IDFS UM team.
✓ Reduced administrative costs
Before
% Of Requests For Acute Inpatient Admissions With Peer-To-Peer Appeals 1.8% 1.6% 1.4% 1.2% 1.0%
✓ Minimized regulatory risks ✓ Opportunities for more efficient payer/provider collaboration
44.7
CY17 vs. CY18
Benefits ✓ Elimination of redundant work
50 45 40 35 30 25 20 15 10 5 0
Aligned IDFS UM Team Average LOC Turnaround Time (Hours)
0.8% 0.6%
1.6%
0.4%
0.5%
0.2% 0.0%
2017
2018
36.6 After
Results