AccURate
Service Overview
Evolving regulatory environment impacting provider
reimbursement
Medicare reimbursements have been declining at many health systems across the
country since the announcement of FY2014 Hospital IPPS Final Rule CMS-1599-F,
including the “2-midnight rule,” in October 2013. To offset this reimbursement loss,
providers are exploring ways to increase their hospital’s top line. Many solutions require
growing volume, changing payer mix or re-contracting; although effective levers, these
strategies can be time consuming and difficult to achieve. More and more hospitals
have discovered that a sizable opportunity to increase their top line exists within their
commercial case utilization review (UR).
Trending issues preventing effective commercial review
processes
Typically most utilization review activities at health systems focus on Medicare Fee-forService patients, and reviews on commercial cases are typically limited and not given
much attention. In even more resource-constrained scenarios, hospitals are unable to
conduct any first level reviews on commercial cases. Without hospital oversight, health
plans determine the case statuses, effectively enabling the payer to manage this patient
population independently. Commercial utilization review programs trend toward an
increased use of observation and frequent incorrect status determinations. As hospitals
investigate the elevated commercial observation rates, they have found a trend in case
management processes. Sometimes case managers grow accustomed to particular health
plans consistently denying inpatient authorization requests. In turn, the case managers
stopped submitting these cases as their UR appropriately indicated, to avoid what they
perceived as an inevitable denial and unnecessary burden.
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Service Overview:
• Maximizes hospitals’ existing case
management function
• Extends consistent utilization review
processes across health plans
• Lowers observation rates and corrects
commercial status determinations to
support accurate reimbursement
• Leverages hospitals’ payer data to
target key health plans
AccURate
When reviewing the financial implications of this trend, hospitals may find there is
a significant reimbursement differential between an inpatient short stay and an
observation case with its health plans. The reimbursement loss caused by an
increased use of observation status can be substantial. The opportunity to address
this issue begins by elevating practices in commercial case utilization review.
Helping fill the utilization review gaps
Designed to support consistent utilization review processes across health plans,
AccURate is a commercial admission review service that uncovers unrealized
reimbursement through effective UR practices. With a flexible and tailored approach,
Optum Executive Health Resources is able to enhance hospitals’ existing UR programs
by offering a comprehensive medical necessity program focused on commercial
admission review. AccURate improves commercial reimbursement rates through
consistent utilization review, active program management, aggressive denials
management on cases reviewed, and on-going monitoring to identify new trends
with health plans.
Engaging health plans in fair financial transactions
Bringing providers and payers together, AccURate from EHR ensures that health
systems’ commercial patient population is held to utilization review standards like
Medicare Fee-for-Service patients. When case managers’ best practices in UR are
applied to commercial cases, the hospital’s team can focus on reviewing those cases
that are clearly appropriate for an inpatient or outpatient setting, and sending our
Physician Advisors the commercial cases that fall in the “gray” area. These “gray”
commercial cases require individual assessmentdue to unclear medical necessity.
Without the added expertise of our Physician Advisors, the hospital may provide
these services under an outpatient or observation setting even though the inpatient
setting was appropriate based on the medical necessity. Through a comprehensive
expert medical record review program, AccURate supports hospitals throughout
the process.
Full spectrum expert support with commercial cases:
Analytics Services — From implementation, to payer engagement targeting
and reporting (annual claims review, benchmarking, weekly/monthly reports),
our analytical team will ensure end-to-end program management enabled by data.
Second Level Review — If during the first-level review, cases fall in the “gray”
area and require individual assessment due to unclear medical necessity, a Physician
Advisor will conduct a review. When patient details are missing from the medical
record, our Physician Advisor will contact the treating physician to address through
a concise and brief conversation. After physician review, a written summary
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Typical “gray” cases include: Chest
Pain, Syncope, Dehydration, Cardiac
Procedures, Mastectomy, Prostatectomy
or Laparoscopic Appendectomy
AccURate
recommending the most appropriate status for the commercial case will be provided
for inclusion in the medical record. Through a concurrent service methodology, our
review is designed to expedite responses when it matters most — while the patient
is still in the hospital.
Denials Management — If a denial is issued by a health plan, our Physician Advisor
will support the hospital with denial management at no charge for internal appeals.
Uniquely positioned to engage payers
No other organization can offer the scale or level of expertise that Optum can; our
experts have performed over 13 million medical reviews for more than 2,300 providers
and 300 health plans. Our company’s track record in providing medical necessity
compliance solutions has only been achieved through an intense focus on an accurate
reflection of the patient’s diagnosis, treating physician’s concerns, and plan of care.
We understand the pressures placed on case management and are an ideal partner
to integrate into the team. By active, consistent utilization review of commercial
cases, a lower observation rate, and increased reimbursement is possible. Many
hospitals leveraging our services have seen decreases by 38% on commercial cases.
Paired with an intense focus on targeting key health plans and correcting commercial
status determinations, fair financial transactions with health plans are possible.
Meet our Physician Advisors:
Our team of Physician Advisors brings together hundreds of physicians representing
60+ medical/surgical specialties who:
•D
raw on the experience of 13 million+ chart reviews and 1.5 million physicianto-physician interactions
•M
eet or exceed national requirements for hospital staff privileges, possess
FACIS Level III verification, and are recertified annually
•H
ave successfully completed eight weeks of our Physician Advisor training
certification upon hire and more than 27 hours of annual continuing
education courses
Discover how the AccURate service can
expand your UR processes:
Call: 877.347.3627
Email: [email protected]
Visit: optum.com
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11000 Optum Circle, Eden Prairie, MN 55344
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