Datacare

Utilization review (UR) organizations need to coordinate the efforts of highly skilled professionals on a tight timetable. This makes modern technology a requirement for a top-performing team.

According to Dr. Doug Benner, who led Kaiser’s occupational health services for 30 years and now serves as medical business product development officer at EK Health, the California-based, URAC-certified utilization review organization, “The DataCare platform provides a more efficient, complete, and accurate utilization review process that saves time, lowers costs, and insures that the right decision is made quickly.”

Here are six ways that DataCare’s advanced technology platform is helping organizations improve treatment, while lowering medical and program costs – and six ways to evaluate whether your platform stacks up.

1. REAL-TIME REPORTING. At EK Health, managers use real-time reports to anticipate and clear bottlenecks and to balance workflows. Operations Manager Terri Clarke starts her day by checking the number of documents in the intake queue and the number of cases pending nurse assignment, to make sure her team gets off to a fast start. At the same time, Dr. Glenn Crafts, head of the UR medical team, reviews a real-time status report that shows all cases by nurse and by stage. By monitoring these key reports throughout the day, they can identify potential problems and quickly reassign cases. The result is that treating physicians receive well-documented authorizations or denials in less than 2.5 calendar days, significantly better than the 5.0 days required by the state of California.
2. ACCURATE STAFFING MODELS. Internal time stamping of all activities allows users to build an accurate model. DataCare clients pull reports that answer questions like “How many minutes does it take for administrative staff to set up a case? How long does it take a nurse to handle prospective, retrospective, and concurrent reviews?” The answers to these questions enable them to develop models that ensure enough staff to provide effective service but no more!
3. IMPROVED QUALITY. According to Denise Glessner, Director of Managed Care at TMC, the managed care arm of Fresno’s AARLA claims administrator, “Since implementing the DataCare UR system, TMC has been successful in streamlining the UR process. The quality assurance component helps us identify when we’re receiving incomplete or inaccurate information from the providers, adjusters, and/or intake staff. In identifying the lack of supporting documentation early, we are able to quickly contact the provider to obtain the necessary information which, in turn, allows us to process the UR quickly, decreasing the delays and costs on the claim.”
4. PROVIDER ANALYSIS. According to the Director of Disability Management at a Fortune 50 self-insured company, “The DataCare system enables both our in-house nurses and those we contract with to document approved procedures using unambiguous treatment codes. After doing this for three years, we have educated our MPN physicians to the point that they now account for less than 1% of our denials. This has contributed to our low medical costs.”
5. DATA MINING. Dr. Richard Thompson, Medical Director of EK Health, says, "We use the DataCare system to insure consistent and proper application of evidence-based guidelines." Dr. Thompson and his team are able to quickly filter cases by diagnosis and treatment codes and then dig down into the medical file to insure that different reviewers are handling cases consistently. For instance, he can pull all spinal surgery cases and check which treatments were authorized or denied and which guidelines were cited.
6. ELIMINATE SILOS. According to the Director of Disability at a Fortune 50 self-insured DataCare client, "Improvements in our UR platform set the stage for a series of changes in our workers’ compensation system which have contributed to holding medical costs constant over the last three years. Because the DataCare system enables us to document treatments using treatment codes, we were able to link the UR system with bill review and automatically verify medical bills against treatment authorizations and denials. This additional layer of verification is lowering medical expenses by 14% to 20% more than when our bill review and UR were not integrated.”

DataCare’s advanced technology is providing many managers with the ability to identify workflow problems before they impact timely medical care or create unnecessary medical expenses.

DATACARE’S SOFTWARE SOLUTIONS:

• Utilization Review & Case Management software – save 25% to 30% of your nurses’ time
• The UR Enforcer (“Bill Zee”) – integrates UR with bill review and reduces medical expenses 8% – 20%
• Express Treatment Approval – enables claims examiners or admins to approve 80% to 90% of treatment requests without expensive utilization review.
• Claims Assistant – much more than an imaging solution; saves 20% to 25% of your examiners time

ABOUT THE AUTHOR.

Mr. Allen is Director of Business Development at DataCare where he helps clients implement advanced technology solutions for utilization review, case management, claims and bill review organizations. He is former Senior Vice President of Group Operations at Guarantee Life Companies (now Lincoln National) where he had an extensive background in managing and re-engineering insurance claims organizations.

Download UM Report.pdf