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A middle-aged man enters an AdventHealth hospital emergency room complaining of shortness of breath, a productive cough, and intermittent fevers. The physician in charge determines that the man has asthma exacerbation and acute bronchitis. The patient is admitted as an inpatient, and after an uneventful stay of two days, improves enough to be sent home.
From a medical perspective, it was a successful outcome. But, that’s not where the story ended for the hospital. After granting initial approval for the inpatient admittance, an insurance company’s contractor conducted a “short stay” audit on the case. The audit found that medical record documents did not indicate that the patient required inpatient care or that outpatient care would have been appropriate. The claim was denied, and the hospital made an appeal for payment to the insurer.
It’s a familiar scenario to healthcare institutions that are faced with highly complex reimbursement rules to get paid for their services. AdventHealth discovered that observation or inpatient decisions led to millions of dollars of insurance payment denials each year. Often, these were the result of a mismatch of patient symptoms and overall health status in medical records with the criteria payors used to support inpatient admission.
Kamron Lachney, regional vice president of revenue cycle operations for AdventHealth West Florida Division, further invested and continued a very carefully orchestrated plan to appropriately place patients in the correct status while decreasing payor payment denials across the division. In 2019, the region corrected, appealed, and overturned approximately $18 million in claims that were initially denied.
Lachney, in partnership with Lynn Leoce, corporate executive director over utilizations management (UM), achieved impressive results by consolidating the patient review process into a centralized unit function under revenue cycle operations (RCO) and by implementing an XSOLIS artificial intelligence tool that assists physicians in determining whether a patient is best served by inpatient admission or short-term observation. The XSOLIS AI tool prompts caregivers to prioritize at-risk claims based on data values reflecting either patient stability or an abnormal state. As a result, it provides guidance for the clinical staff to appropriately provide the patients the proper status and appropriate quality care.
“Few people in healthcare truly envision the operational impact of AI. Kamron has made that impact happen for AdventHealth,” says Joan Butters, CEO and cofounder of XSOLIS. “Kamron has shown himself as a true innovator and the results speak for themselves.”
“These interactions help educate the clinicians on documentation and best practices, again providing the best care for our patients.”
Prior to the centralized UM initiative, each hospital or physician’s practice handled these appeals individually. The revamped approach created a Centralized Utilization Review Team that manages all pre-bill denials. Today, medical decision-makers can contact physician advisors on the review team via a dedicated extension whenever they encounter denials. Well-versed in the statusing of admissions and documentation improvement initiatives to ameliorate claim outcomes, physician advisors help physicians identify additional information about a case to boost the chances of a successful appeal.
One physician advisor is assigned to deal with each and all payors, providing a single point of contact between AdventHealth West Florida Division and the payor. “Advisors build relationships with major payors,” Lachney says. This allows AdventHealth to better understand the payor’s principles regarding claim denials, and the payor to better understand AdventHealth’s strategy toward patient status and what is deemed medically necessary regarding the patients’ clinical indicators.
“We encourage challenging denials when it’s right for our patients,” Lachney says. With one point of contact, the back-and-forth interactions with payors are simplified. Now, there is no need for multiple calls or emails to track down the right person to address specific case reviews at the facility. These case studies are leveraged to provide further education for leadership and clinical staff. Both the AdventHealth West Florida Division RCO physician advisor and the payor physician peer continually develop a rapport and peer-to-peer understanding while reviewing patient cases.
This arrangement has another advantage. The centralized approach enables standardization on claims documents, increasing accuracy across the organization—which in turn also reduces denials. Previously, having each practitioner address their own denials yielded more inconsistent claim outcomes. “You could have one physician documenting a case completely differently from another,” Lachney says. “The payor looks at the records of pretty much the exact same case, and because the notes are different, one may get paid and the other denied.”
The regular contact between AdventHealth’s physician advisors and each payor also allows AdventHealth to learn how to better approach tailored stances conflicting opinions document cases, Lachney adds. That knowledge, accumulated by the Centralized Utilization Review Team, then benefits the entire organization.
One of the salient features of the AI tool is a series of prompts based on automated algorithmic logic of trending patient data points. The tool assists in calculating and weighing specifics in patients’ medical history given their current conditions. It creates guidance and provides a numeric score that indicates whether the documentation is supportive of an inpatient stay or otherwise.
The tool has been very beneficial and continues to be enhanced. “There are still gray areas,” Lachney says. “That’s when the physician can call a dedicated extension and speak with UM subject matter experts or our physician advisor team. These interactions help educate the clinicians on documentation and best practices, again providing the best care for our patients.”
The AI system is simply a tool to help clinicians think “whole care,” using the providers’ expertise to determine status—observation or inpatient. It’s not the sole determinant. “It’s ultimately up to the physician,” Lachney emphasizes.
Eliminating all inpatient claims denials is not a realistic goal, Lachney acknowledges. There will be cases when a physician feels strongly that an inpatient stay is necessary, and the payor will simply not agree. AdventHealth continues to ensure that the best care for the patient is provided regardless. “It’s about looking at these encounters and putting effort toward what is appropriate for our patients,” Lachney says.
The combination of the Centralized Utilization Review Team, the RCO Physician Advisor Team, and the AI tool will continue to enhance payment turnaround time and reduce medically necessary denials. The result is an organization with improved financial health that maintains a high quality of care.
