| Case Management/Utilization Management/Denial Management

Case Management/Utilization Management/Denial Management

Quality offers consulting services to organizations that are interested in improving their Utilization Review / Case Management Departments medical necessity admission, continued stay, and denial management processes. UR/ CM programs are evolving with the move toward Value Based Care, Bundled Payments and Risk Sharing Contracts. It is time for a check-up to see if your current model is achieving outcomes and is operational aligned to generate bottom line financial and clinical results for better revenue cycle. In the last decade UR and CM functions were merged into one but now with cash flow critical to an organization’s success, it is imperative to re-examine workflows and processes to identify what is working and what is not. A third party audit of both your UR/CM department and Revenue Cycle Department can be valuable in making measurable improvements and proactively decreasing length of stay, denials and readmission’s.


Who should consider consultative services?

  • Rural Hospitals
  • University Hospitals
  • Hospital Systems
  • Clinical integrated healthcare systems
  • Health plans and Health Insurance Marketplace
  • Accountable Care Organizations (ACOs)
  • Centralized UR Departments
  • Utilization management and case management companies
  • Community and Regional Hospitals

Our Experience and Service Offerings

Quality’s executive team’s credentials include actual work experience developing Utilization Review and Case Management programs aligned with revenue cycle management. As part of our services, we provide a comprehensive needs assessment, gap analysis and develop detailed action plans to build a more cohesive UR/Case Management and Revenue Cycle Management Department. Quality consulting services jump starts your organizational operations to effectively respond to the demands of bundled payments, Medicare readmission penalties and effective progression of care

What we offer as part of our UR/CM and Revenue Cycle Management Evaluation Services

Quality’s experts will assist your organization with a needs assessment and Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis. We will perform an onsite needs assessment and provide you with a detailed report of our findings with recommendations.

The UR/ CM and Revenue Cycle Management Evaluation of services will specifically observe your operations and review opportunities for improvement to include:

  • Organizational structure and leadership
  • Identify priorities and time lines for organizational change and specific needs
  • Review UR / CM models best for your setting
  • Identify areas to improve alignment with Revenue Cycle Management
  • Evaluate payer mix and payer-driven methodologies of authorization and re-authorization
  • Identify barriers to progressive of care and solutions
  • Observe UR and Transition of Care assessment skills of case managers as well as quality of documentation
  • Review appropriateness of admissions including two-midnight rule processes/ documentation
  • Evaluate Emergency department and the planned admission processes
  • Patient documentation- estimated time patient will require hospitalization, continued medical necessity
  • Identify recommended tools and education needs of case management staff
  • Review training and orientation curriculum
  • Review readmission rates and length of stay
  • Review missed opportunities to convert observation stays to in-patient stays
  • Evaluate the initial 24-hour level of care assessments performed and patients / families expectations for admission /discharge
  • On-Site UR/ CM Model Implementation Support
  • Webinar and Onsite Education Training
  • Future Design Case Management Model Development
  • On-Site Interim Case Management Director Support

Clinically Focused Revenue Cycle Action Planning

It has never been more critical for the financial stability of hospitals and health care systems to implement sustainable clinically focused revenue programs that interface with case management, admitting, clinical documentation and chart capture. As part of our service offering, Quality can also provide a team of revenue cycle experts that can implement specific programs such as mandatory bundled payment, analyze and improve revenue cycle process and develop training curriculum:

  • Interim Utilization Management Director
  • Interim Case Management Director
  • Interim Senior Financial and Accounts Receivable Analyst
  • Interim Business Office Director Support
  • Interim Revenue Cycle Director Support
  • Interim Patient Financial Services Director Support
  • Interim HIPAA Security or Privacy Director / Manager Support
  • Interim CFO Support
  • Interim ACO Population Health Director Support
  • Interim Health Plan Support
  • Interim Technical Revenue Cycle Business Analyst
  • Interim Staffing for software design, testing, integration and implementation

Benefits to your Organization

  • Avoid painful, expensive mistakes, problems, and surprises
  • Obtain third party independent audit recommendations
  • Improve organizational efficiency and productivity tailored to your organization
  • Learn from others who have successfully accomplished UR/ CM Department implementations
  • Address organizational and resource concerns by bringing objective and experienced expertise to work side by side with your people
  • Implement appropriate work process changes that meet your business initiatives and goals