Case Study: Toney Healthcare Utilization Management Impact
Plug-and-Play Clinical Expertise:
Admissions Review & Inpatient Backlog Reduction, Rapid Savings
The utilization management (UM) department for one region of a large, national health plan was underperforming—not only was the team not operating to standards, but it had inefficient workflows and a huge backlog of inpatient cases. Further, utilization management nurses were not applying admissions criteria properly, with significant financial implications for the plan and health risk for its members.
Toney Healthcare was engaged to provide comprehensive utilization management and best practice expertise. After transforming the department’s operations to improve collaboration, efficiency and compliance, our clinical experts went to work to reduce the backlog and stress-test the new organizational design. The result? The entire panel of backlogged cases was cleared, admissions were reviewed and optimized, and the new organizational design was proven in action. Plus, Toney Healthcare drove over $1M in savings in just one line of business, in one month, from two hospitals.
$1,021,792
admissions review savings from just two hospitals in a single month
900 backlogged cases cleared
in just 10 days
25 to 30 cases
processed per day per nurse, including hospital negotiations
< 5% error rate
error rate in MCG criteria selection
ELIMINATING BACKLOG:
RAPID DEPLOYMENT OF CLINICAL RESOURCE
Toney Healthcare rapidly deployed an entire team of clinical resources, all with managed-care experience, and managed the team’s work and quality performance. As a first step, Toney Healthcare addressed the inpatient case queue—a backlog of more than 900 cases, many one or two months old. In just 10 days, applying the best-practice processes implemented during the organizational transformation effort, the Toney team eliminated the entire backlog and brought the queue completely up to date. All clinicians worked within the health plan’s systems as an integrated part of the health plan’s utilization management team, empowering the plan with full transparency and reporting.
ADMISSIONS REVIEW:
CLINICAL APPROPRIATENESS OF CARE
The Toney Healthcare UM team seamlessly transitioned to a retrospective admissions review for the commercial members of two hospitals, a process that the plan had not previously performed. Applying MCG criteria, the Toney team identified those cases that did not meet inpatient criteria and worked with the hospitals to negotiate a change from inpatient status to a more appropriate observation status or emergency department stay. The few cases where the hospital and the Toney nursing staff were not in agreement were sent to the medical director for review—only 13 cases of the 2,740 cases reviewed.
$1.02M IN SAVINGS GENERATED IN ONE MONTH
While the health plan medical director’s review missed some savings opportunities by allowing a few cases to remain at inpatient status despite not meeting MCG inpatient criteria, the Toney-led admissions review generated a huge reduction in cost. In just one month at two hospitals, more than $1M was saved based on the health plan’s own claims reconciliation. The Toney team was also highly accurate, achieving < 5% error rate in MCG criteria application.
As important, the admissions review stress-tested the organizational transformation to make sure policies and procedures were working, people and departments were communicating, and everybody understood their role. After the process was complete and all 2,740 cases were addressed—and the health plan’s utilization management nurses were fully trained by Toney Healthcare—the health plan took over management of the program.
