Utilization Review: Implementing a “Tight” Process to Prevent Errors

Why not prevent errors from occurring in the beginning?

I recently attended a brainstorming session that was designed to focus on a clinical department and find ways to improve its function and outcomes. This brainstorming is just in the initial phase, and the moderator is non-clinical, but rather a process improvement engineer. The thought was to have someone who will objectively look at the functions and processes involved, and apply standard industry principles to look for areas of improvement. The group involved is composed of seasoned professionals in this clinical area.

During the last session, we got into a discussion about the processes and components involved in healthcare revenue cycle prior to billing, and what is done to make sure that there are no errors that need to be corrected prior to submitting a bill. Although there are probably many of these components, two came to mind during the conversation:

• There are computer programs referred to as “scrubbers” that look for these errors. Now, according to Merriam-Webster, a scrubber is defined as an “apparatus for removing impurities.” In this situation, it is a computer program removing errors involved with billing.
• The other component at the end of the clinical episode that comes into play is “quality” or “quality control.” This has been defined as “an aggregate of activities (such as design analysis and inspection for defects) designed to ensure adequate quality, especially in manufactured products.” In this particular instance, it is the clinical process, not manufacturing, although an analogy will be made shortly.

The moderator noted that it seems like an inordinate amount of time and effort is placed on correcting errors at the end of the clinical encounter, so that a correct claim can be submitted compliantly. He questioned why there isn’t more effort placed on prevention, which will reduce workload and time needed to correct. Some of the responses from the brainstorming team indicated that prevention is not really possible, as the hospitalization process has so many components to it. 

Prevention requires standardization and accountability in order to be successful. One executive I worked with years ago took a look at a “simple” hospital process, that of an order for a complete blood count (CBC) being placed, and the result ending up in the medical record. He analyzed the process to see how potential errors could occur. Amazingly, that number was over 200. Could you imagine that happening on an auto manufacturer assembly line, or on a much larger scale, say, the production and launch of the Saturn 5 rocket? Does the end product of a car or space vehicle need a “scrubber” before the final product is launched? Yes, there are quality checks along the way, but they are more for validation of the prevention process, not correction.

In the healthcare industry today, there is a developing significant push towards prevention versus treatment (correction). Why should this concept not be applied to healthcare processes, a patient’s hospitalization, or an episode of care? Why not try and prevent errors from occurring, instead of trying to correct them after they have occurred?

Moving toward this concept may seem overwhelming at first, but it should not be. It simply entails acquiring data and knowledge of where and when the errors occur, what scrubbers find, quality concerns, and other indicators, followed by analyzing the results and instituting prevention measures with implementation of processes.

Sounds pretty simple, right? It’s not, as it will take a concerted effort, but it should be well worth that effort. Let’s face it, the payers have figured it out. They have processes in place to find missed errors, lacking documentation, and quality deficits. Why not prevent them from occurring in the beginning?

The best place to start would be utilization review (UR), with the implementation of a “tight” process. This will require precise, accurate, compliant knowledge of the UR process, followed by a gap analysis. This analysis is like building a puzzle. The picture on the box reveals the intended result. The individual pieces are the parts of the process that need to be connected to attain that result. Applying the puzzle analogy to the UR process will yield interviews of leadership and staff to find out how they are completing their parts of the process. Are there bottlenecks or constraints leading to workarounds? Data needs to be collected, collated, and summarized. Then, one should look at the end results that have been achieved in the past, and what needs to be corrected. As part of this analysis, payer denials need to be categorized and investigated. What are the documentation deficiencies, as it pertains to justifying medical necessity? There may be many other involved factors, and establishing dashboards will help – and subsequently, they can provide a good mechanism to judge the success of these preventative measures.

The UR process requires a physician advisor (PA), period. This position can and should be a big component of the preventative process. But the PA must be well-trained, and must have a good knowledge base of clinical medicine, medical necessity, and federal regulations. There must be a willingness to provide the PA service, to be available as needed, to have a good relationship with the UR staff, physicians, and executives, and to be on-site. Remote services are good for backup, but are not helpful to institute and implement preventative measures.

Granted, there will be payer egregiousness that comes into play with prevention, and it must be dealt with. The challenge is gauging whether these payers follow, change, or don’t follow their own rules. In addition, there is a human factor complicating preventative processes. Is artificial intelligence (AI) an answer? AI could help standardize the process, to a certain extent, but human intervention is still needed to muddle through complicated, unpredictable times.

There are movements afoot to head toward a denial-free environment. Standardization of processes and accountability for actions are key factors that can improve prevention. Remember the old idiom, “an ounce of prevention is worth a pound of cure.”

If one puts in the effort to prevent a problem, one will not have to put a lot of effort to solve the problem.