Reframing the Payer-Provider Relationship

Reframing the Payer-Provider Relationship

It’s safe to say that the provider and payer relationship can be contentious at times, often due to the subjectivity involved in the utilization review (UR) process. But what if it was possible for payers and providers to work hand-in-hand to reduce unnecessary administrative burdens and streamline utilization review, while also maintaining their commitment to high-quality patient care? That was the journey recently taken by Covenant Health and Humana—with help along the way from XSOLIS.


Source: Reframing the Payer-Provider Relationship

Population Health: Adding Up Value in Healthcare

Population Health: Adding Up Value in Healthcare

Value-based care, population health and social determinants of health (SDoH) are terms that seem to pop up everywhere for those who work in healthcare. But they aren’t just buzzwords or passing fads, they are sources of both true potential and frequent misinterpretation. As the healthcare industry shifts to value-based reimbursement models, many hospital leaders are reevaluating their strategies to better prepare for the transition—and many believe that focusing on population health is the key to success.


Source: Population Health: Adding Up Value in Healthcare

New Year, Renewed Knack for Medical Necessity

New Year, Renewed Knack for Medical Necessity

Utilization review was first introduced during the 1960s as a solution to combat the rising costs of healthcare by reducing overuse of resources and identifying waste. Health plans began reviewing claims for medical necessity and hospital length of stay, requiring the physician or the utilization review (UR) nurse to show that the chosen plan of care, treatments and procedures were medically necessary and appropriate.


Source: New Year, Renewed Knack for Medical Necessity

Centralizing the Utilization Review Process

Centralizing the Utilization Review Process

In a breakout session at XCHANGE 2019, Rena Arden, corporate supervisor of utilization management at Knoxville, Tennessee-based Covenant Health, shared the lessons learned when the health system centralized its utilization management process. Because each of Covenant Health’s seven original facilities had their own case management (CM) and utilization management (UM) department, the process involved a lot of moving parts. At larger facilities, commercial UM operated separately from the combined Medicare UM/CM model, and at smaller facilities, the distribution of reviews depended on the availability of staff. Healthcare regulations change all the time and keeping up would be difficult if UM remained in separate hospitals, Arden explained. Needless to say, centralizing the process was critical.


Source: Centralizing the Utilization Review Process

Leading Through Constant Change

Leading Through Constant Change

Transitioning to a new software system and new related workflows can be difficult—so how can leaders help their teams stay grounded during the process and work more efficiently? That’s the big question that Lynn Leoce, executive director at AdventHealth; Debbie Schardt, director of revenue cycle and utilization management at MultiCare Health System; and Sherri Ernst, corporate manager of revenue integrity at Covenant Health, sat down to discuss during a panel discussion at XCHANGE 2019 entitled: “Leading Through Constant Change.” P. Michelle Wyatt, director of clinical best practices at XSOLIS, led the following Q&A:


Source: Leading Through Constant Change