Ensuring A More Collaborative and Consistent Approach to Utilization Review and Case Management

West Tennessee Healthcare

Optimized Processes Yield 2.4X ROI, Save >200 Hrs. in 12 Mo

Debbie Ashworth, Executive Director of Care Management, and her team at West Tennessee Healthcare knew they needed more consistency in the utilization review and case management processes. Due to the manual nature and subjectivity of their utilization reviews and case reviews, there was variability in both processes including the information sent to payers. Also, Debbie felt like they were missing opportunities to convert patients from observation status to inpatient status and were missing potential revenue.

Ensuring Staff Efficiency and Outperforming the Observation Rates of Their Peers

An early win for West Tennessee Healthcare was the decrease in their observation rate after the implementation of the Xsolis platform in July 2022. West Tennessee experienced a reduction in their observation rate of 7.5%, from 21.4% (in the 12 months prior to go-live) to 19.8% from August 1, 2022, to July 31, 2023.

According to Debbie, “As a result of using the Xsolis platform, we have decreased our observation rate while getting patients into the appropriate admission status in a timely manner.” Xsolis has also helped to streamline Debbie’s team’s processes, while providing a level of support unlike other vendors. The biggest benefit of Xsolis, according to Debbie, is standardizing her staff’s processes, eliminating variability. Additionally, Debbie and her team appreciate the consistent support that the Xsolis team provides including:

• A dedicated Account Manager, Clinical Engagement Consultant, and Business Analyst that meets with the West Tennessee Healthcare team consistently to view reports and track data related to the observation rate, observation to inpatient conversions, “exception” cases (missed opportunities to convert), denials, nurse reviews/productivity, and more.
• Clinical rounds that occur once per month, during which Debbie’s team chooses cases for the Xsolis Physician Advisor and utilization review subject matter experts to use as examples to lead discussion and education about the cases, how they would review the case for appropriate status determination, and more.
• Onsite Quarterly Business Reviews once every quarter during which the dedicated XsolisS team presents what is working well, the updated ROI, and opportunities to ensure the Xsolis platform is being leveraged to its full potential

Optimizing Payer Connections and Collaboration to Drive Positive Health Outcomes

West Tennessee worked with Xsolis to optimize their payer connections, including a large national payer, at the beginning of 2023. Dragonfly, formerly known as CORTEX, is a framework for connecting payers and providers on the Xsolis platform. Through this framework, payers and providers utilize Xsolis’ analytics, including the Care Level Score™ (CLS™) to arrive at a consistent basis for decision-making. The CLS is a numerical representation of the likelihood of appropriate status for each patient, which is powered by Xsolis’ real-time predictive analytics and machine learning and is continuously updated directly from the EMR, based on the full spectrum of patient data.

According to Debbie, “My team’s collaboration and communication with payers has been enhanced as a result of the Xsolis platform, allowing both payers and West Tennessee access to the same platform.” Further, the CLS can be leveraged to automate inpatient determinations that have historically been agreed upon between the two entities with Precision Utilization Management (UM), so that no faxes, emails, or phone calls are necessary. The use of Precision UM in collaboration with a large national payer resulted in 22.7% of West Tennessee’s cases being automated from January 1, 2023, to July 31, 2023, saving a total of 205 hours.

Achieving A Substantial Return on Investment

Apart from reducing their observation rate, increasing their staff’s efficiency, and optimizing their payer connections and collaboration, the Xsolis platform has led to a substantial return on investment (ROI) for West Tennessee Healthcare. From August 1, 2022, to July 31, 2023, West Tennessee Healthcare experienced a 2.4X ROI, equating to $1,764,700 from utilizing the Xsolis platform.

Xsolis has also helped identify Medicare inpatient only (IPO) procedures that would have otherwise slipped through the cracks and been missed. In addition to tying into the surgery schedule to automatically catch cases by CPT codes, Xsolis’ AI-driven technology also identifies likely IPO cases based on the documentation in the EMR.