Utilization Management

Medical necessity documentation education is included with each review.

Compliant Patient Status That Protects Revenue

Payors are increasing efforts and utilizing various tactics to deny inpatient level of care. To effectively mitigate these efforts, it is essential to utilize physician advisors who have experience and expertise in combating payor tactics. We support hospitals and physicians with timely and compliant expert status determinations.

Why Brundage Group

Internal physician advisors often do not have the expertise or resources to design, implement and manage programs effectively. Physician advisor programs supported by Brundage Group allow clients to leverage the expertise of our experienced physician advisors who are the industry leaders, as well as our proprietary analytics dashboard and case management software tracking solutions that set the standard for industry best practices.

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Overturn Rate & Effective Overturn Rate

Overturn Rate & Effective Overturn Rate

How We Can Help

We provide compliant documentation education with each case review to equip physicians with the knowledge to appropriately and compliantly status patients. Our expert physician advisors help determine:

Which cases to review

When to review the cases

When to involve our advisors

Peer-to-Peer Support

We have interacted with payors on thousands of peer-to-peer cases and have established valued, credible relationships with many of the health plan medical directors. Our extensive experience & expertise allow us to recommend which cases to proceed with during the peer-to-peer stage and generate an effective overturn rate for our clients.

Once a peer-to-peer is requested, we contact the payor within 24 hours to coordinate and resolve a peer-to-peer review, and immediately communicate the outcome back to our hospital client.

Industry Benchmarking and Technology Insights

Through the thousands of cases we have completed, we track data to help hospitals measure performance against industry benchmarks and make recommendations based on best practices and proven outcomes.

We use proprietary data analytics to identify areas of opportunity in real time so your organization can quickly adapt to make changes that will immediately impact the revenue cycle.

Our clients see a positive impact on revenue with our utilization management support ensuring accurate reimbursement for the high-quality care provided to the community.

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Observation Review

The Critical Timeframe

Scrutiny is necessary as the observation hours increase. Failure to improve within the observation timeframe often supports the medical necessity of hospital inpatient admission. Observation patients should be reviewed frequently and escalation to a physician advisor should occur when appropriate. The physician advisor review will clarify when medical necessity is present for inpatient admission or discharge to ambulatory care is clinically appropriate. High-quality and timely communication with the attending physician and the utilization management nurse are paramount.

Effective case management is a key component to a hospital’s throughput

Our physician advisors act as liaisons between hospital case management departments and attending physicians to help render opinions regarding utilization of resources, continued stay and admission status based on sound medical judgment.

We promote physician efficiency and strengthen communication between providers and case management with the goal to make hospitals more efficient and optimize the length of stay (LOS).

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Our high-quality, compliant, physician-based solution can support a model that works for your organization

Our compliant status determinations are performed by experienced physician advisors and include medical necessity education. Overwhelmed with denials? We can also help manage payor denials to protect revenue. Our physician advisors are experienced in working with all payors and apply best practices to succeed on appeal.

Concurrent (in-house) case reviews

Observation, inpatient and continued/extended stay reviews

Retrospective (post discharge) case reviews

Proprietary analytics to optimize your healthcare system’s revenue cycle

Gap coverage nights and weekends

Denials management, including peer-to-peer and appeals support

Educational approach that includes compliant medical necessity documentation education

Proprietary analytics to optimize your healthcare system’s revenue cycle

Gap coverage nights and weekends

Denials management, including peer-to-peer and appeals support

Educational approach that includes compliant medical necessity documentation education

What is improper level of care costing you?

Insurance companies have a team of people working to protect their revenue, and so should you. Improper level of care may be costing your organization thousands of dollars per admission. Our expert physician advisors base all status determinations on sound medical necessity criteria with effective documentation to ensure accurate reimbursement for providing high-quality care.

Why is Utilization Management Important?

Utilization management plays a crucial role in revenue management and optimization for hospitals. It is vital for several reasons:

Optimizing Resource Allocation

Utilization management helps hospitals make informed decisions about resource allocation. By ensuring that resources, such as hospital beds, diagnostic tests, and surgical procedures, are used efficiently and judiciously, hospitals can maximize their capacity to treat patients in need.

Cost Control

Healthcare costs continue to rise, and effective utilization management is essential for controlling expenses. By reviewing the appropriateness and medical necessity of services, Utilization management helps identify unnecessary or inappropriate care, reducing wasteful spending and mitigating financial strain on patients and healthcare providers.

Enhancing Patient Safety and Quality of Care

Utilization management promotes providing high-quality care by ensuring that patients receive the right care at the right time. Potential risks and adverse events can be identified through the review process, and appropriate interventions can be implemented to enhance patient safety and improve clinical outcomes.

Compliance and Risk Mitigation

Utilization management helps hospitals comply with regulations and guidelines set forth by regulatory bodies and payors. Hospitals can minimize the risk of audits, denials, and potential legal repercussions by ensuring that services are delivered within established medical necessity criteria and documenting the rationale for care.

Revenue Optimization

Proper utilization management is directly linked to revenue optimization for hospitals. By accurately documenting medical necessity, improving coding and billing practices, and minimizing denials, hospitals can capture appropriate reimbursement for the care they provide. This supports financial stability and enables hospitals to invest in improving patient care and expanding services.

The Goals of Utilization Management

Brundage Group recognizes that the goals of utilization management are pivotal for driving revenue and optimizing healthcare operations. Our comprehensive solutions align with these goals to ensure hospitals achieve optimal outcomes.

Ensuring Medical Necessity

At Brundage Group, we prioritize ensuring providers can accurately demonstrate medical necessity. Our experienced physician advisors collaborate with hospital staff to carefully evaluate the clinical appropriateness of services and procedures. By adhering to evidence-based guidelines and industry best practices, we help hospitals ensure that the care provided is medically necessary, improving patient outcomes and supporting accurate reimbursement.

Enhancing Quality of Care

We passionately believe that utilization management should focus on enhancing the quality of hospital care. Through our comprehensive services, including clinical documentation education and peer-to-peer support, we enable hospitals to achieve excellence in care. By identifying opportunities for improvement and implementing best practices, we empower hospitals to deliver high-quality, evidence-based care that exceeds industry benchmarks.

Controlling Healthcare Costs

Brundage Group understands the critical role utilization management plays in controlling healthcare costs. Our solutions help hospitals minimize unnecessary or inappropriate services, reducing wasteful spending and optimizing resource allocation. By carefully assessing the medical necessity and appropriateness of care, we enable hospitals to make informed decisions that drive cost savings without compromising patient safety or quality of care.

Improving Patient Outcomes

The ultimate goal of utilization management is to improve patient outcomes, and this is a core focus at Brundage Group. Through our expert physician advisors and comprehensive case management support, we enhance patient safety, promote timely interventions, and optimize treatment plans. By ensuring that patients receive the right care at the right time, we contribute to improved clinical effectiveness and positive patient experiences.

Revenue Optimization

Brundage Group recognizes that revenue optimization is a fundamental goal of utilization management. We work closely with hospitals to ensure accurate reimbursement for the high-quality care they provide to their communities. Our proprietary analytics, benchmarking data, and expertise in managing payor denials help hospitals protect their revenue and maximize appropriate reimbursement. By optimizing coding and billing practices, we empower hospitals to achieve financial stability while maintaining compliance with regulatory guidelines.

At Brundage Group, we are committed to helping hospitals achieve these goals. Our comprehensive services, knowledgeable physician advisors, and advanced technology solutions ensure that hospitals can successfully drive revenue, enhance patient care, and maintain financial sustainability. By partnering with us, hospitals can confidently navigate the complex landscape of utilization management, knowing they have a trusted and experienced ally.

Frequently Asked Questions

How does Brundage Group support hospitals in utilization management?

At Brundage Group, we offer comprehensive utilization management solutions tailored to the specific needs of hospitals. Our services include physician advisor programs, documentation education, peer-to-peer support, industry benchmarking, technology insights, observation review, and effective case management support. We provide expert physician advisors who collaborate with hospital staff to ensure compliant and appropriate status determinations, optimize resource utilization, and streamline communication between providers and case management.

How does Brundage Group help hospitals in revenue protection?

Our physician advisors are experienced in working with commercial payors and applying best practices to succeed on appeal. We help manage payor denials, protect revenue, and capture appropriate reimbursement for providing high-quality care. Through our proprietary data analytics, we identify areas of opportunity in real-time, enabling hospitals to adapt quickly and make changes that immediately impact the revenue cycle.

What makes Brundage Group stand out in utilization management?

Brundage Group stands out due to our deep clinical expertise, comprehensive revenue cycle solutions, and commitment to excellence. Our experienced physician advisors are industry leaders in providing compliant documentation education for case reviews. We leverage proprietary analytics, case management software tracking solutions, and industry benchmarks to drive optimal outcomes for our hospital clients. Our focus on education, collaboration, and revenue protection sets us apart and positions us as a trusted partner for hospitals seeking to enhance their utilization management processes.

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