By implementing an in-house physician adviser program and improving aspects of its overall case management model, one children’s health system was able to position the organization to improve the quality of care and drive significant financial benefit.
With over 1 million patient encounters each year, this children’s health system is one of the largest pediatric healthcare systems in the Southwest. The organization realized that...
With over 1 million patient encounters each year, this children’s health system is one of the largest pediatric healthcare systems in the Southwest. The organization realized that inefficiencies in its case management process and insufficient physician review processes needed to be resolved to provide a quality care experience for patients and their families and to avoid potential revenue losses stemming from payor denials and write-offs.
Leadership at the organization and Huron analyzed the existing case management model, working to identify and address core problems such as duplicative work, gaps in the process and a lack of clarity regarding roles and responsibilities. The team determined that a dedicated physician adviser program would be essential to improving patient status management, denials management and overall case management. Improvements focused on the following:
Implementing in-house physician review processes. To further support the organization’s clinical documentation improvement, case review and communication with payors, the team developed a physician adviser program. The program is staffed by internal talent with a comprehensive understanding of the organization’s patient populations, payor mix, physicians and payor relationships. By working with Huron to develop the in-house physician adviser program, the organization avoided the cost and inefficiency of an external partner. The program also fostered internal partnerships between clinical and finance teams, helping reduce denials and potential lost revenue.
Increasing consistency in the case management review process. By establishing clear governance structures and connecting roles to specific responsibilities, the organization was able to ensure each case received a consistent level of review. This increased accountability in the case management process and helped staff identify opportunities to capture revenue that would have otherwise been missed. Through peer-to-peer reviews, physician adviser resources helped ensure documentation reflected patients’ medical necessity and acuity.
Streamlining the care experience. Implementing a consistent case management process helped prevent duplicative work, reduced the review time for each case and simplified care delivery across the care continuum. The improved case management model and the physician adviser program helped to optimize case management and improved communication across disciplines and between inpatient and outpatient teams. This was instrumental in coordinating resources and services, which enabled the organization to better meet the needs of patients and their families.