With a background in consulting and auditing, I had fresh eyes when I began my current role as Director of Revenue Integrity and Utilization Management at the Knoxville-based Covenant Health. Some areas for opportunity or improvement were immediately identified, and many of these observations have stuck with me over the past four years as a blueprint for how we could do things differently to transform utilization management (UM) in our current healthcare system. Frank B. Gilbreth Sr. said, “I will always choose a lazy person to do a difficult job because a lazy person will find an easy way to do it.”
As an outsider to the utilization management department, this message resonated. When I was just weeks into my current role, I wondered why UM processes were so hard. The traditional solutions seemed outdated and mired down staff with manual work that should not exist in this day and age. Faxes have been phased out in the majority of businesses, and yet, at least 70% of healthcare providers still use them to exchange medical information. Such inefficiencies were chief sources of friction during the case review process internally and with our health plan partners.
Call me lazy, or simply blame it on a new perspective coming into the UM area of healthcare, but I believed there was a more efficient way than the technology solutions we were using at the time to alleviate this friction. Finding an easier or better way has fueled my work in utilization management, and it has also influenced my department’s impact on efficiency and innovation throughout the larger Covenant Health system.
In my quest toward improvement, I believe there are three Vs that underscore the main goals of healthcare organizations today.
Volume
Any time healthcare leadership centralizes a department, they are seeking economies of scale – essentially, “how can we do more with less?” With a predicted shortage of 1.1 million registered nurses across the country by 2030 – not to mention the exacerbated effects of COVID-19 on pre-existing healthcare staffing issues – the challenge has never been truer than it is today. My colleagues and I are constantly reassessing among our teams how we can better utilize resources or services within another area of the organization.
Viability
How can we sustain our operations? At the hospital system level, we are constantly pursuing excellence while simultaneously adjusting to what we know the industry is doing – even as the healthcare system is moving to more of an outpatient environment. In the midst of the aforementioned staffing shortages, we are further challenged to secure revenue when we can.
Variability
Our healthcare market is filled with variability. With so many different technological tools in the industry that we could use at any given time, it’s good to keep in mind that we are ultimately all chasing the same goal in utilization management – getting patient status right.
To course-correct on any one of the challenges as outlined above, and certainly to pull all three levers, we must:
(1) Communicate better – within payer or provider networks and between them.
Communication must be secure, and these disparate entities must also coexist within the same technologies, preferably using the same real-time data views, to improve efficiency and workflow as we work together toward the same end goal in UM – ensuring the patient is given the right care at the right time, in the right setting at the right cost. While acknowledging payers and providers have sometimes misaligned incentives, when both groups are presented with a data-driven matrix for accelerated, data-driven decision-making, our conversations become more elevated and focused on the true clinical merit of each patient or member. AI or ML-driven tools can further augment solutions when providers and payers work together to establish agreed upon thresholds for more automation and time savings. Are we going to agree and get things right every time? Certainly not. But it is easier when you experience improved communication from the seamless exchange of information.
(2) Ask the tough questions.
How do our numbers compare against peers in our region? What are they doing that we should learn from as we look to improve? Am I using my staff to their fullest potential? Do our retention numbers and job satisfaction rates reflect this? How can we stop the clicks and get information from Point A to Point B as fast as we need it to get there?
In full disclosure, change management in UM can be challenging because you are working with highly experienced nurses who are used to doing things a certain way. But I have found that when you are open to beginning these tough conversations, and willing to look at clinical or administrative problems from different angles, even the most experienced staff tend to admit there is room for improvement. Manual UM processes take the luster out of what technology can offer, and our industry has suffered from the shared impacts of this long enough. When the right tools are employed, teams can instead feel empowered and more fulfilled with their jobs, as though they have been given a digital assistant. Nothing is more valuable than the gift of time, and my staff appreciates this while also commenting that they find their jobs more rewarding now as well.
(3) Acknowledge that collaboration is possible.
It’s hard to accept that true collaboration can be achieved between providers and their payer partners when we’ve been taught the status quo in healthcare administrative is acceptable because it is simply too hard to change. In essence, we’re taught the fight is not worth having because we’re up against archaic processes that have been in place for too long. However, I’ve found that every journey to transformation begins with internal buy-in, and I was lucky to have like-minded change agents join me on this journey for Covenant Health as we’ve transformed our UM processes.
For others who are just getting started, it is hard to argue against a better way when you’re able to prove that UM review times can go from 15 minutes down to 5 minutes with the right solutions at play. Newfound efficiencies allow staff to move to other areas of focus, such as education, working denials or conducting other advocacy work. Not to mention, these same solutions can also right-size observation rates and uncover revenue opportunities that were being missed before.
In my experience, this is the most shared value in moving to an AI-driven UM technology – the time savings for both providers and payers and the increased alignment when using objective data sources, which reduce friction and open the door for collaboration. As we’ve learned and grown together with our payer partners, we’ve been able to increase trust on both sides that the analytics and data being used are accurate – reiterating that there is also shared value in the learning process and getting more cases right the first time together.
Best of all, when providers and payers work together in tighter collaboration to do what’s right for the patient or member, the end result is a real behavioral change for both provider and payer teams that has ripple effects throughout the industry. This approach can transform the way these two entities collaborate across the nation to ultimately create a better health system for all.
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About the Author
Sherri Ernst serves as Revenue Integrity and Utilization Management Officer for Covenant Health. After starting separate clinical auditing and denials departments at Covenant, Sherri was tasked with leading the charge in transitioning Covenant to a centralized UM team from the ground up for the nine acute care facilities in East Tennessee. Sherri’s extensive clinical background includes stints as an RN and NICU nurse, in addition to experience in consulting in the revenue cycle space.
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