- Using AI to Streamline the Provider-Payer Relationship
The relationship between providers and payers is key to ensuring that patients and beneficiaries move through their care journeys efficiently, but challenges such as administrative data management, information exchange and communication issues, and siloed data can make the utilization management process more difficult.
The press release also highlighted the issues of patient status and medical necessity determinations. Appropriate patient status helps avoid denials and reduces back-and-forth between payers and providers, leading to more efficient care.
"This is a challenging time for provider organizations across the U.S.," said Christine Pearson, chief financial officer at AnMed, in the press release. "By providing an automated, objective view of medical necessity, XSOLIS will help increase the efficiency of our existing staff, so that we can better serve our patients."
The CORTEX platform is designed to help ensure correct patient status and streamline the utilization management process by using real-time predictive analytics to continuously assign an objective medical necessity score and assess the anticipated level of care for each patient.
At AnMed, the platform has inbound and outbound integration with the health system’s EMR, allowing AnMed staff to use advanced case management analytics and reporting capabilities to drive efficiencies between its Utilization Management and Physician Advisor teams.
Other health systems are also taking advantage of AI to help improve their relationships with payers and streamline operations.
In December, HealthITAnalytics interviewed Debbie Schardt, assistant vice president of revenue cycle and utilization management at MultiCare Health System, and Alana Llewellyn, concurrent review nurse manager at Coordinated Care, to discuss how AI has helped each organization improve information exchange and utilization management.
MultiCare and Coordinated Care, like AnMed, leverage the CORTEX platform as part of their strategy to bolster provider-payer relations and streamline utilization review and management.
Specifically, MultiCare uses the platform for multiple aspects of its utilization review process, including assisting nurses during case reviews, prioritizing cases, and communicating with payers, physician advisors, and other members of the utilization review team. Similarly, Coordinated Care uses the platform to support its communication with providers and augment its utilization management process.
Schardt and Llewellyn said that since implementing the platform, they have seen significant benefits, including reduced administrative work and unnecessary back-and-forth, the ability to prioritize high-risk cases, and increased employee engagement and satisfaction. The platform also allows both organizations to better track cases and other performance metrics, creating a wealth of useable data that can inform future efficiency efforts.
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