The COVID-19 pandemic created extreme staffing shortages across the entire healthcare delivery continuum. According to the 2023 State of Nursing report conducted by Nurse.org, 62 percent of the nurses surveyed continue to feel burned out, and overwhelmed due to ongoing staffing shortages, and uncertainty about the future. Of those surveyed, 91 percent of the nurses believe the shortage is getting worse, and 79 percent report that their units are inadequately staffed. Care management was not excluded in the workforce shortages. Many hospitals are facing challenges to retain seasoned, experienced staff, and maintain a balance between those experienced and those new to the role. This has resulted in lost revenue from missed inpatient opportunities or the acceptance of observation status due to the overwhelming volume of cases requiring an appeal.
Utilization management (UM) has been challenged across the country. Utilization review is a specialized field requiring skill and experience to match the patient’s clinical picture with evidence-based criteria to appropriately support medical necessity. With the staffing shortages, many hospitals are struggling to adequately cover all patient units within the hospital. Organizations often settle for filling the needed positions with newer nurses that do not have the requisite experience or proper training. For these same reasons, the quality and oversight of the reviews have suffered. The inappropriate use of evidence-based criteria, or lack of a consistent review process, has led to an increase in payor denials and lost revenue. A strong, comprehensive utilization review process is key to placing the patients in the supported admission status from the start, as well as providing successful requests for appeals. A strong UM program will verify the patients are receiving the right care at the right time, ensuring organizations are delivering the most cost-effective care.
Centers for Medicare and Medicaid Services (CMS) requires any hospital receiving Medicaid or Medicare reimbursement to have a utilization review plan to review the services provided by the institution to determine medical necessity. However, many hospitals lack the expertise to develop and train the nurses in a best-practice, comprehensive model to promote the ideal outcome. Concurrent utilization review should occur for all medical cases placed in a hospital bed. All cases that do not meet the evidence-based criteria should be referred to a physician advisor. Every step of the review process should be documented, to demonstrate a consistent process for every patient and to benefit the hospital in appealing medical necessity denials.
UM has significantly evolved over the years. As reimbursement rates have dropped, the importance of a comprehensive UM process, ensuring the right care is being provided at the right time, is critical to optimizing the organization’s revenue. A program that provides consistent, experienced staff to augment the delivery of high-quality, cost-efficient care, will result in a decrease in denials, improved revenue, as well as decreased readmissions and healthcare costs.
