BIG’s Utilization Review Application| What it means for Patients and Healthcare Payers

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Bits In Glass’ Utilization Review Accelerator| What it Means for You

by Jonathan Delulis, Bits In Glass

The Challenge for Patients and Healthcare Payers:

It can be difficult for patients to navigate through their continuum of care when they need to go outside of their Primary Care Physician’s (PCP’s) office. Most often these external visits require a referral from their primary care physician (PCP), and it means that the patients will need to engage with their health insurance provider to determine whether they are authorized to receive the services. This insurance utilization review can occur at any time during and after the delivery of the services.

While referrals are one of the most common practices patients will encounter, it’s often one of the most frustrating due to approval wait times. Unlike most goods or services consumers order online, a healthcare referral does not come with a tracking number or a progress bar where they can follow the progress of their claim through the system and these days customers are demanding speedy, transparent, and efficient services that challenge healthcare payers to find a way to meet their expectations.

The Solution:

The Utilization Review Accelerator that Bits In Glass (BIG) recently launched on the Appian App Market helps insurers meet the customer expectations by reducing the complexity of the referral process, shortening the approval cycle, and building efficiencies into the referral process to quickly and accurately evaluate the medical necessity of the patients’ request. The app assists payers in providing the member and their PCP with the feedback necessary to manage their care plan regardless of whether the request is being made prospectively, concurrent to care, or retrospectively.

Easier, Faster, and More Efficient Request Processing

  • For member services representatives, the Utilization Review application provides an easy to navigate standard form that allows administrators to receive and input the requests via phone or fax whether obtained by a patient, a subscriber (should they be calling on behalf of a dependent/spouse), or a physician. The care management teams then assess referral requests either from individuals or shared queues and prioritize and order them with target delivery dates based on the data in the referral, such as it’s level of urgency or service category.
  • Depending on the complexity and content of the referral type, the referral can be directed through one or several levels of approval to ensure that each request receives the appropriate level of assessment. If the referral has a clear outcome based on configurable business rules, it can be automatically approved or denied to expedite the turnaround time.
  • Organizationally, the Utilization Review application provides ongoing reporting on approvals, denials, pends, and voids, and is capable of handling key pieces of member communications such as approval letters. Acting as dataHUB for the healthcare organization to leverage data visibility and reusability for other applications as needed. Armed with this information, healthcare payers increase their ability to support their member’s continuum of care and mitigate downstream issues with claim adjudication.

The Opportunity:

Healthcare payers drive new enrollments by keeping their existing member base satisfied. By improving and automating key pieces of the Utilization Review process there are benefits beyond managing commercial membership – payers can effectively manage and support Medicare and Medicare Advantage (MA) populations as well.

For those organizations looking to expand in Medicare Advantage, there are additional considerations given to the manner in which payer’s manage this government-sponsored population. The Centers for Medicare and Medicaid Services (CMS) provision star ratings to all participating organizations based on the following criteria:

1. Staying healthy: screenings, tests, and vaccines
2. Managing chronic (long-term) conditions
3. Plan responsiveness and care
4. Member complaints, problems getting services, and choosing to leave the plan
5. Health plan customer service

Leveraging the Utilization Review accelerator empowers organizations to successfully support the Medicare Advantage population and provide data-driven auditable evidence to CMS to increase their revenue potential. 

To watch a demo of the Utilization Review application please go here.

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What is an Appian Accelerator?

An Appian Accelerator on the AppMarket covers the core functionality for a particular business function. It provides Appian customers with a “running head start” so they can expect to complete their Appian implementation in less than half the time as compared to starting from scratch. An Appian application can reduce risk, reduce implementation timelines, deliver applications that are Appian Certified as compliant with Appian Best Practices and, most importantly, reduce time to value and that means ROI starts in weeks, not months. 

The best part is that customers can still overlay their specific business needs or “secret sauce” on top of an Appian Application by working with our team of domain experts and Appian technical consultants.

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About the Author 

Jonathan has over 8 years of experience in Healthcare IT, providing services in both Payer and Provider organizations. He is responsible for delivering custom solutions to Bits In Glass’ customers and is passionate about improving how healthcare is delivered through technology. Born and raised in the Boston area, he’s an avid fan of the Celtics, Patriots, and Red Sox and if there isn’t a game on he’s probably playing with his dog Sully.

About Bits In Glass

Bits In Glass is an award-winning IT consulting firm that enables you to solve complex business problems with systems that make your business operate faster, easier and more efficiently, empowering you to outpace your competition, drive rapid growth, and deliver superior customer value.

We are the partner of choice for many business transformation projects, partnering with market leaders who are disrupting and driving transformation in every aspect of modern business, from intelligent systems that automate smart processes to enriching customer experiences to changing the way we build applications and accelerate growth across the organization.

Find out why leading technology companies partner with Bits In Glass including Appian (Business Process Management), MuleSoft (API-Led Systems Integration), Blue Prism (Robotic Process Automation) and Salesforce.com (Customer Relationship Management).