PGodfrey_Automation of Utilization Management

Running Head: UTILIZATION MANAGEMENT AUTOMATION

Utilization Management Automation for Care Management Organization.

Paul Godfrey, MBA, BSN, RN, MSN Candidate

Rutgers University, Newark NJ

School of Nursing

NINF5405: Advanced Practice in Nursing Informatics

Faculty Advisor: Rose P. Estrada, DNP, RN, BC, CPN

Preceptor: Deidra Brown, RN, MSN, NP

Facility/Address: Montefiore Care Management, 200 Corporate Blvd, Yonkers, NY 10701

April 1, 2015

UTILIZATION MANAGEMENT AUTOMATION 1

Abstract

Utilization management is sometimes not given a high level of priority in the cycle of

patient care but could hinder the progression of care when not managed properly. The turnaround

time between service request and approval or denial is crucial in an emergency situations and

automating the system could greatly impact the time interval. When an inpatient facility is an out

of network facility and unrelated to the care management organization, before inpatient

hospitalization information is communicated to the care management, the patient may be re-

hospitalized and lack proper follow up. One trigger for outpatient follow up utilization activity is

inpatient activation notification. Approval process cannot be completed until all required

information is received by the payer or payer representative. Some payers have contract with

care management organization that are responsible for authoring or denying care requests.

The business of health care is complicated but the end result is health of the patient. The

process must be synchronized and all parties involved in authoring service and caring for the

patient must have an effective communication strategy to facilitate best health outcome for the

patient. Disjoint and uncoordinated system of communication will lead to silo process and

becomes an impediment to the utmost health outcome of the patient. When collaboration

between care coordinators and care facilities is encouraged and implemented, all entities will

work effectively for the patient.


Project Description

Automation of utilization management improves patient outcome. As patients discharge

from inpatient care management to the community, there has to be a better process of notifying

care coordinators who could follow through with outpatient appointments. In cases where

inpatient information is not shared with external care coordinators, the turnaround time between

notifications could be precious and sometimes contribute to re-hospitalization which increases

cost of care and unhealthy condition for the patient. Another important issue is the process of

approving care request with greater emphasis on patients requesting outpatient care and waiting

extended time for communication from the payer. Most of the communications with the

utilization management entities are through the phone system but if automation is provided

where patients/members can access the system of use and request a service which should be

channeled to a work queue, this will reduce turnaround time between service request and

response.

At Montefiore CMO, a legacy system called CCMS is used for utilization management.

Some of the processes involved in utilization management using CCMS are not automated,

thereby not effective in facilitating faster care management for the members. Epic tapestry is

being implemented to replace CCMS utilization management for Montefiore CMO. Emphasis is

on functional requirement which CMO would anticipate to be part of the Epic tapestry solution.

Project Scope

The scope of this project will highlight the expected functional requirements and how

they would help to foster a more effective utilization management. Emphasis will also be on

transitioning to a new approach with respect to educating the staff, members, and providers on

how to utilize an improved automated process to improve the workflow. This project will


include analysis of Inpatient and Outpatient Utilization Management. The scope will also include

providing insight into the relationship between effective utilization management and optimum

patient health outcome. The culmination of analysis in this project will lead to contrast the

present CMO utilization management with a legacy system called CCMS and a new system

called EPIC Tapestry with emphasis on the Montefiore CMO functional requirements. Finally,

care continuity relationship with automated utilization management will be explored. Improved

system must be utilized to yield expected result and to this end, educating the Montefiore CMO

staff and providers on how to utilize an improved automated process to improve the workflow

geared toward member care management will be the ultimate goal of the Montefiore Center for

Innovation and Learning

Project Goal and Purpose

Utilization management involves patients, care providers, and payers. Show how

automation of the process of utilization management can help to improve care outcome. When

the patient, care provider and payer can communication effectively, the ultimate result will be

best outcome for the patient and cost saving for the payer and thereby allowing the care provider

to reach more patients. Using the concept of distributed system to provide utilization

management will allow care management entities, members to be served, and service providers

to communicate effectively and foster faster turnaround time between service request and service

provision.

Institute for Healthcare Improvement (IHI) qualifies the effective management of health

care utilization with the concept of Triple Aim, which entails population health improvement,

enhancing the patient experience of care with respect to quality, access, and reliability, and

finally reducing or at least making effort to control the per capita cost of care. (Cornett, 2012,


p13). Waste and abuse could also be reduced when information about health care utilization

could be shared between service providers.

Project Objectives

Utilization Management (UM) allows for managing health care costs by evaluating

authorization requests for services and procedures. Requests from providers must be handled by

applying CMO and health plan requirements in a manner that is correct, fair and uniform. Rules

can differ greatly among health plans and lines of business. Authorized services must be aligned

with the member’s benefit coverage, and where possible, services should be directed to in-

network providers.

UM is an area subject to periodic health plan audits. Documentation of proper steps and

outcomes is crucial. Staff needs to be guided as much as possible to ensure both quality and

quantity are being achieved. There are regulatory requirements for the amount of time a health

plan has to respond to a request.

Problem identification and Assessment

CMO receives preauthorization requests from various sources, for example, an

application called Post-n-Track, telephone, fax, and mail. If an authorization was submitted via

an external source like Post-n-Track, the system will create the authorization in real time with a

distinct authorization number and record the source of the request. In order to create an

authorization, a core set of mandatory data fields must be entered and validated. The system

must provide the ability to configure and employ required data validation checks upon saving an

authorization. The system must also take the appropriate action upon failure of a data validation

check. The authorization should only be created if all of the specified validation checks succeed

and if all of the required data fields are present.


The authorization intake process must also accommodate requests when a member and/or

provider are not present in system at the time the request is received. The system must support

workflow to facilitate the research and resolution of provider and member issues as well as

support the correction of the request with the correct provider and member records. The current

manual workflow needs to be automated where possible.

Currently, the legacy system does not provide sufficient validation, nor does it enable the

user to complete entering requests expeditiously. The system does not provide the ability to

configure application-based validation logic that checks for correct and meaningful data.

Additionally, the system does not provide the ability to derive or filter lists based on the data

entered on the authorization.

Stakeholders and Organizational Culture

CMO’s strategic goals are focused on achieving success in several programs that are

closely tied to national health care reform efforts. To maintain consistency and alignment with

the Montefiore Medical Center, the goals are divided among four areas—Innovation and

Learning, Improve Internal Processes, Customer’s View and Finance and Growth.

The CMO has taken the lead in Montefiore’s participation in two of the most important

health care reform programs of the Patient Protection and Affordable Care Act: the Pioneer

Accountable Care Organization initiative of the Center for Medicare & Medicaid Innovation and

the Health Home program of the New York State Department of Health.

While the programs deal with different populations (Pioneer with Medicare fee-for-

service beneficiaries and Health Homes with Medicaid beneficiaries), the central elements of

both involve care coordination of patients with chronic conditions, especially those with high

cost and complex cases.


The major stakeholders for this project within Montefiore organization are CMO-MIS,

Montefiore-MIT, CMO-DAR, CMO-CMPE, CMO-CLI. The technical stakeholder is

Montefiore-MIT, the reporting and analysis stakeholder is the CMO-DAR, The business

requirement stakeholder is the CMO-CMPE and the clinical training and knowledge transfer

stakeholder is the CMO-CLI. External vendors are interviewed and invited for deep dive sessions

with the hope of signing a contract. EPIC application has been identified as the most probably

application to replace the legacy CCMS in performing utilization management functionalities of

Montefiore-CMO.

Project Executing Process

The final project sign off is performed by the senior management of Montefiore and the

vendor senior executives. Each functional requirement is signed part of the approval process.

Each department providing any aspect of the functional requirement obtains a signed copy by

each department senior director. The work breakdown structure contained within the project

schedule is approved and signed by each lead senior director. Collectively, all signed

components are signed by the Montefiore senior executive and countersigned by the vendor

senior executive before implementation.

Project Monitoring

Weekly update meetings are scheduled to discuss the progress of the development team

and answer any question that may arise. Montefiore has dedicated in-house Epic teams who were

sent to training at the Epic headquarters and became the liaison between Epic and Montefiore

organization. This allows for constant monitoring of the development team. Testing is

performed as a component of the whole system is completed. This helps to identify errors which

could derail the lunching of the system if not corrected.


AS-IS Workflow


To-Be Workflow


Project Plan

Gido and Clement (2012) explained that “It is necessary to lay out a roadmap, or game

plan, that shows how the project scope will be accomplished within budget and on a schedule”

(p11). The triple constraints of a project are scope, time and budget and if one aspect is affected,

there will be a deviation of project plan. The general plan of this project is handled by

Montefiore MIT. The problem identification involves the subject matter experts from the CMO-

MIS, CMO-DAR, CMO-CMPE, and the utilization management staff across the CMO NCM and

CMO-UBA. The training and knowledge transfer to existing and new staff is under the

leadership of the CMO-CLI department. The identification of external vendor is under the final

sign off of Montefiore senior leadership. The automation of utilization management is viewed as

crossing many functional departments of Montefiore but CMO UM department handles the

intricate of authorization and denials. They are viewed as the subject matter experts in the area of

Inpatient and Outpatient utilization management process with respect to member s enrolled in

care management program of Montefiore.

The Montefiore MIT is the highly technical team that will initiate the functional

requirement related to infrastructure. Questions like connectivity issue, reliability of servers,

sharing of information, backup capabilities, and system architecture. The CMO-DAR is

responsible for identifying reports to be derived from the system. They will come up with

functional requirements that will cover all the operational and clinical reports needed by each

department. The functional requirement in this area will seek to make sure that the Utilization

Management Application will draw inference from internal and external data sources to produce

all needed reports. The CMO NCM and CMO UBA are the subject matter experts and are

closely familiar with how the users will interact with the system to derive expected results. The


business requirement documentation is tasked with collecting all the functional requirements and

a major component of this document is user interface, attributes, task attribute, rules engine

functionality, collecting questionnaire from users, drafting the as-is workflow and the to-be

workflow, and interacting with selected vendor for deep-dive sessions. The CMPE team

coordinates the activities of CMO NCM and CMO UBA by leading and organizing meeting

sessions.

A major component of the project plan is scheduling user training post implementation.

The CMO-CLI is tasked with documenting training materials. They will be responsible for

assessing the skill levels of the staff and determine the extent of training needed to bring the staff

to productivity level with the new system. The legacy system functions with manual task and

external local file whereas the new system will have automated task and ability to trigger tasks

using rules engine. The staff has to understand how to use the task system and disposition each

appropriately.

Human Resource Management

Montefiore has implemented a hiring freeze which may make human resource

management more dire than previously anticipated. One of the most important aspects of a

project is using the right people for the right task. As employees change positions within and

outside the organization, it is imperative to backup list of capable staff to utilize when needed.

The concept of having dedicated staff for Epic under Montefiore has provided a great human

resource management strategy which will help to see the completion of the project. The hiring

freeze did not have an impact because dedicated staff have been committed and trained for this

project.


Project Schedule and timeline


Project Cost Analysis (Tangible and intangible Benefits)

Within any project, different aspects of cost estimates are performed, for example

aggregated total cost, budgeted cost, cumulated cost, actual cost, committed costs, earned value,

a cost performance index, cost variance, and a cost forecast (Gido & Clement , 2012, p261). As

part of a larger organizational information technology project, the utilization Management

Application is embedded within the Epic System. Tapestry is the Epic system component


designed for utilization management and Montefiore is leaning towards using Epic for this

solution.

Montefiore is making effort to comply with meaningful use requirement of the

Affordable Care Act. Towards this goal, there is a bundle of Epic Application which Montefiore

is presently implementing, for example Inpatient, Ambulatory, Tapestry, etc. The tangible cost of

the utilization management is part of the total contract between Epic and Montefiore. The

intangible benefits are faster turnaround time between member service request and response,

ability for the users to have a rules engine which will drive task assignment, ability for the

system to schedule call task and enabling the user to document call outcomes.

Project Quality Management

The provided functional requirement serves as a yardstick used as benchmark for quality

measures. All completed components of the system are tested based on the provided

requirements. Test cases are developed for different levels of the test team. All errors are

documented and submitted to the development team for correction. Some of the quality control

techniques used in project management are Cause and Effect Diagrams, Control Charts, Flow-

Charting, Histogram, Pareto Chart and Pareto Analysis, Run Charts, Scatter Diagrams, Statistical

Sampling, and Inspection (http://www.brighthubpm.com).

Project Risk

There is inherent risk of development taking longer time than approved. The utilization

management system is a subsystem of the automation effort and the resource allocation may not

be enough to deliver this portion of the system at the previously approved time. Changes in

provider policy which governs utilization management could add a layer of delay to the


development as new policies are implemented. Authorization and denial process differs from one

provider to another and could also complicate the utilization automation effort.

Project Communication

Web enhanced communication mechanisms are used to arrange and hold meetings

involving major stakeholders on a weekly basis. All participants connect using their personal

computer and telephone. All stakeholders are encouraged call others on a regular basis and keep

the lines of communication open. Once a month, in-person meeting is held and all major

stakeholders are invited to discuss progress of the project and address any outstanding issues.

Project Reporting

The project plan update is circulated to all major stakeholders as part of the project

reporting effort. Each department receives updates related to their task. Within communication

through email, the reporting updates are included as attachments.

Ethical and legal considerations

The Montefiore legal department is responsible for reviewing all contracts for legal

implications. The scope of the utilization automation project is limited to receiving requests for

service and approving or denying the request. A major component of ethical consideration is to

understand the process and follow the guidelines provided by the payers otherwise called the

insurance company or government entity. The rules of approval are set, which covers number of

days to wait for additional information pending a request and clinical guideline for approval or

denying.


Analysis of project outcome and success

Epic was invited as part of the project implementation to interview all the Montefiore

Utilization Management subject matter experts. Functional requirements provided by Montefiore

MIS were reaffirmed by Epic in several meetings. The difference between an open architecture

and closed architecture is the ability to change system functionalities without incurring much

additional cost of ownership. The Epic implementation team spent a reasonable amount of time

to show Montefiore Utilization Management team how to apply the Montefiore CMO functional

requirement to corresponding Epic Tapestry functionality. Workarounds were discussed and

demonstrated. Where gaps exists between Epic functionality and Montefiore CMO functional

requirements, workarounds are introduced because Epic does not ascribe to customization

because of the resources needed and the closed architectural nature of their application.

The inpatient Montefiore application will be integrated with Epic Tapestry because all are

Epic applications. Using Epic solutions for both the inpatient and outpatient utilization

management makes it easy for all Montefiore care management members who have inpatient

admission within Montefiore network to be linked with the proper care manager. Care continuity

is greatly enhanced as a result of using the same system for both inpatient and outpatient. Delay

in authorization comes when a Montefiore care management member is hospitalized within an

out of network facility. A general practice that can help in this situation is the inclusion of

assessment process for all inpatient cases. Questions related to care management organization

responsible for a patient could be collected at admission. The process of sending notices can be

automated using communication platform which will upload such notices into the utilization

management application for quicker processing thus enhancing care continuity.


Task management system embedded within the Epic Tapestry will be used to allocate

tasks to a team of utilization management staff. They will be able to use a pull of centralized

available task to select cases of members to work on. This will be a great improvement from the

legacy CCMS system which uses notification only between users and has no task management to

be used for task assignment. Utilization management involves application of rules with time

sensitivity. Keeping track of how many calls must be made, how many letters must be sent, and

other mandated communication before denial of request is a daunting task. Requesting additional

information from facilities also involves call tasks and all communications must be documented

and used in appeal cases. Epic tapestry provides a repository of attributes where all needed

information will be stored and retrieved as needed within the approval or denial cycle.

The success of deploying Epic Tapestry for Montefiore utilization management will be

measured by how proficient the staff is able to use the system and achieve maximum output. To

this end, the Montefiore CMO-CLI is tasked with scheduling in-class training for all levels of

users. The first level of training performed by Epic is the train-the-trainer sessions. The group

selected for this training sessions are mainly the Montefiore CMO-CLI. They will in turn

schedule the super user training and run small classes enabling the super users to learn and

demonstrate understanding of the system by taking written test of contents taught.

There is a delay in schedule with respect to implementation of Epic Tapestry. Montefiore

system of utilization management is different from many facilities because there is the CMO sub

division of Montefiore that will handle outpatient scheduling and care coordination. Facilities

without a care management subdivision will naturally discharge a patient after inpatient car, this

reduces layers of complexity. Montefiore has to coordinate discharge from inpatient care with

CMO and this layer of complexity was different from what Epic is used. CMO is not a


department of Montefiore but an organization with all levels of management affiliated with

Montefiore. Epic has to find a way to provide a solution that will be effective and thus the delay

in implementation.

Conclusions

As assessment is performed and diagnoses are being established, there has to be approval

of service. If the process is inefficient and causes delay in approving needed health service, the

outcome may be life threatening or fatal. If service is performed but not approved, the service

provider may run the risk of using extraneous ways to collect money from the patient.

Sometimes, the patient may not be in the position to discuss such transactions or make payment.

Automation of utilization management will shorten the time it takes to approve a needed health

service and also provide a rule based task system which users can employ to drive activities

needed in the process of receiving and processing service requests. Cornett (2012) stated that

“UM is the evaluation of medical necessity, appropriateness, and efficiency of the use of health care

procedures and facilities.” (p16)

All care requests are scrutinized for medical necessity before approval. If requested treatment is

necessary and appropriate, then information must be submitted by the requesting facility in cases of

inpatient and facility not owned or affiliated with the care management company. A cohesive process

predicated upon automation will be very useful and improve the outcome of care by eliminates lengthy

approval processes. In outpatient approval process, the process is lengthier because the member has to

notify the care management organization in that outpatient care service is needed. The request will be

processed and coverage verified before process of medical necessity is triggered. An automated process

can allow the user/member to interact with the organization’s system and update coverage information if

needed before making a request for service. A system that allows members and facility to seamlessly

enter request and get result will no doubt eliminate delay and improve positive care outcome.


References

Cornett, B. S. (2012). Utilization Management and Accountable Care: Compliance Oversight as

Organizational Stewardship. Journal Of Health Care Compliance,14(5), 13-20.

Cunningham, C. O., Sohler, N. L., Cooperman, N. A., Berg, K. M., Litwin, A. H., & Arnsten, J.

H. (2011). Strategies to Improve Access to and Utilization of Health Care Services and

Adherence to Antiretroviral Therapy Among HIV-Infected Drug Users. Substance Use &

Misuse, 46(2/3), 218-232. doi:10.3109/10826084.2011.522840

Gido, J., and Clement, J. P. (2012). Successful project management, Fifth Edition, South-Wester

Cengage Learning, Mason, Ohio

Harrison, P. L., Pope, J. E., Coberley, C. R., & Rula, E. Y. (2012). Evaluation of the

Relationship Between Individual Well-Being and Future Health Care Utilization and

Cost. Population Health Management, 15(6), 325-330. doi:10.1089/pop.2011.0089

http://www.brighthubpm.com/certification/72854-a-roundup-of-quality-control-tools-and-

techniques/, retrieved 3/25/2015

Maclure, M. (2005). Drug Insurance Utilization Management Policies and“Reference Pricing”:

An Illustrated Commentary on the Article by Vittorio Maio and Colleagues. Milbank

Quarterly, 83(1), 131-147. doi:10.1111/j.0887-378X.2005.00338.x

http://www.brighthubpm.com/certification/72854-a-roundup-of-quality-control-tools-and-%09techniques/

http://www.brighthubpm.com/certification/72854-a-roundup-of-quality-control-tools-and-%09techniques/

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PGodfrey_Automation of Utilization Management