10 One tool to review them all and in the end reimburse them!
Year: 2024
Type: conference-abstract
Abstract: Background Healthcare systems today face a complicated system of reimbursement with constantly evolving payer criteria. On the Utilization Review side, a lot of resources are spent to keep medical necessity, in patient only and 2-midnight denials minimal. Objectives Identify a multi–functional process to optimize and track Peer to Peer conversations and their outcomes. Set up a robust, semi–automated methodology using a web–based database to ensure gaps in process are addressed. Visualize the data in a meaningful manner so payor contracts may be optimized. Methods In 2021, Intermountain Health set up a unified peer to peer (P2P) process with one of our biggest payors with Physician Advisor Services (IPAS) doctors reviewing medical necessity denials on one day a week. By 2022, we found there were many payors in the system, with no process for P2P or a way to track the cases and get them reimbursed. Our IPAS team partnered with Care Management and Intermountain Appeals Unit (IAU) teams to develop a robust process to funnel all P2P discussions through IPAS and ensure they got reimbursed. Results The impact of this intervention has been the ability to track and ensure that encounters are undergoing a P2P conversation and getting reimbursed what was agreed to. In just over a year and a half of starting this process, our IPAS team has reviewed close to 3000 cases and overturned more than $35 million in denials (figures 1 and 2). This is a huge accomplishment for the system, and helps the patient get the care they deserve without having to burden them with the bill. Conclusion Identifying all stakeholders and setting up a process using a semi-automated tool (figures 3 and 4) to transfer cases between various teams ensures opportunity cases are worked and billed accurately.
Institution: Intermountain Healthcare
Language: English
Subfield: Economics and Econometrics
Domain: Social Sciences
Open Access status: gold
OpenAlex ID: W4404895233