Forward-thinking hospitals have long recognized clinical documentation integrity (CDI) and utilization management (UM) as priorities for a successful revenue cycle. The current economic climate only underscores their importance. The latest performance trends data from Strata Decision Technology noted that, while operating margins remain stable, payment volumes experienced a shortfall of nearly 18% in Q1 of 2024.
Now is the time for hospitals to explore how to further automate and integrate their CDI and UM functions. These improvements have clear financial implications, not only because they lead to faster approvals, fewer denials and more effective communication with payers, but also for the role they play together to improve resource utilization. There are clinical benefits, as well – accurate documentation of necessary treatment can enable real-time, evidence-based decision making that improves outcomes.
CDI and UM are priorities, and there’s a growing movement to take a more holistic view of both.
Hospitals use CDI to ensure the integrity and accuracy of clinical documentation for patients – from vital signs to lab results to ongoing consults – to maximize efficiencies, capture more revenue and optimize the allocation of resources. The goal is to collect complete and accurate documentation which can support optimal patient care, regulatory compliance, quality improvement efforts as well as stand up to the scrutiny of payer approval processes.
UM teams also have a vested interest in documentation accuracy in order to help establish medical necessity, ensure the appropriate status for patients, and comply with local, federal, and payer requirements. Success in these areas helps foster efficiency within UM teams, and reduce downstream denials. However, ever changing and complex payer rules regulations also add to the challenges faced by already stretched UR teams. A common example is demonstrating medical necessity under the recently-clarified two-midnight rule. In addition to managing timely communications with payers, UM teams need ironclad information to demonstrate inpatient as the medically appropriate patient status, when physicians believe a patient needs inpatient care as opposed to observation care. In light of changing policies, rising denial rates, and growing hospital costs, the stakes of having reliable and accurate documentation have never been higher.
While hospitals have embraced technology and workflow updates to streamline CDI and UM, until recently, health systems haven’t taken an integrated view of these processes.
CDI is at its best when patient records are up to date, but busy clinicians rarely have time to transcribe their notes in between encounters. As such, CDI teams are handed incomplete information in clinical documentation, as well as by lack of resources and inefficient query processes.
Meanwhile, and very separately, UM nurses review case documentation to confirm delivered care is justified and that the patient’s stay is still defensible to a payer– yet all too often, clinical data is hard to find or even missing from the record, making it difficult to compile and send required info to payers within narrow timeframes. Nurses must also juggle phone calls, faxes, and emails from payers in order to navigate approvals. For a process with significant implications for whether a hospital is fairly paid for the care it provides, such inefficient manual workflows are critically outdated.
Use technology to automate the process for a more holistic view of the patient
Fortunately, technology readily available today is positioned to augment clinical judgment into CDI and UM, offer care teams and administrative professionals a more holistic view of the patients they’re treating, and bring CDI and UM together to generate further value for an organization. One example is leveraging artificial intelligence to analyze a patient’s records, communicate with physicians, and update payers.
Modern AI-driven solutions rank patients based on their current – and projected – conditions, letting CDI teams know which records need updated information. The system also identifies additional risk factors that haven’t been explicitly documented but may be present based on other information in the record. Smart querying capabilities with all relevant information empowers a physician to provide an answer in minutes, capturing accurate documentation of the patient’s clinical picture.
A similar approach informs UM teams that a patient currently on observation status should be admitted (or vice-versa) based on the evidence in their record. Seamless physician engagement technology enables streamlined communication between UM nurses, Physician Advisors and Attending Physicians enabling higher response rates and faster response times. Once the care team makes that decision, the system could then streamline the uploading of the curated clinical documentation to the payer’s portal, saving time and preventing the “phone tag” that often leads to delayed approvals or denials
Bringing CDI and UM together: Benefits the entire revenue cycle
When patient records are shared but workflows are siloed, business units end up applying the same information to their own KPIs. Improved documentation may meet the needs of CDI, but it may not be shared with the UM team to help justify a decision to admit a patient.
Looking at these workflows more broadly and holistically, and in doing so leveraging purpose-built technology to improve them, benefits the entire revenue cycle. For example, breaking down silos between UM and CDI enables UM nurses to access relevant information at the right time and strengthen the case for medical necessity. Better documentation leads to accurate claims coding and appropriate representation of a patient’ status, which reduces the likelihood of denials and gives organizations a clear audit trail if one does occur.
With provider burnout and staff shortages at an all-time high, solutions that can streamline communication between providers and ease their burden in day to day practice are crucial.
The impact on clinical and business outcomes is even greater. When care teams have access to up-to-date records and analytics tools capable of gleaning key insights from that information, patients get more timely access to the care they need – and organizations can rest assured they will be properly paid for delivering that care.
About Priti Shah
Priti Shah is the Chief Product and Technology Officer at Iodine Software. Shah has more than 20 years of corporate and product strategy experience. Prior to Iodine Software, Shah served as Chief Product Officer at Finvi (formerly Ontario Systems) where she was responsible for developing Finvi’s product portfolio strategy and roadmap.