Using AI to Streamline the Provider-Payer Relationship

DISPARATE TOOLS LEAD TO INEFFICIENT INFORMATION EXCHANGE

As with any collaboration, the partnership between providers and payers relies heavily on the tools each participant has at their disposal. Schardt noted that there are various tools that providers and payers can use for utilization review and utilization management, as the Centers for Medicare & Medicaid Services (CMS) do not require one standardized tool across the board.

The ability to choose which tool to use can be a good thing, but this can also present one of the major challenges causing pain points between providers and payers, she continued. Disparate data and analytics tools can create friction in information exchange — another challenge payers and providers face when collaborating.

“When communication doesn’t go smoothly, you end up with a back and forth, which can cause abrasion for everyone,” Llewellyn explained. “Combined with the fact that both sides are held to their own contractual obligations, exchanging information can become quite painful for everyone.”

To overcome these challenges, MultiCare and Coordinated Care have adopted the XSOLIS CORTEX platform, an artificial intelligence (AI)-driven solution designed to support collaboration between payers and providers by assigning medical necessity scores and assessing the anticipated levels of care for patients.

LEVERAGING AI FOR UTILIZATION REVIEW AND MANAGEMENT

Both organizations have implemented the platform to help streamline their overall utilization management strategies in combination with other tools, such as EMRs and case review teams. 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.

Coordinated Care also uses the platform to support its communication with providers and augment its utilization management process.

“[The platform] gives us access to tons of different data points and has allowed us to set a precision utilization management scoring range of 120 and above, which has proven to be an effective range for determining an individual’s inpatient status,” Llewellyn stated. “This analytics threshold is jointly agreed upon by payer and provider, and all cases above this threshold are automatically approved as appropriate inpatients, drastically reducing administrative work as there’s little to no back-and-forth.”

MultiCare has also seen significant benefits from using the platform and its AI capabilities.

“First, we streamlined our efficiencies significantly,” Schardt said. “Utilization review has a history of trying to review every case every day, and really the industry can no longer support that — UR departments can't support that anymore. So, what's nice about the efficiency [of the platform] is that we can really focus in on high-risk cases.”

Schardt also explained that MultiCare’s implementation of the platform has increased efficiency by boosting employee engagement and satisfaction.

“The people who are reviewing these cases are nurses, and any other tool does not allow them to use their clinical thinking or [allow the industry to] use the nurses to the top of their license, whereas [this AI platform] does,” she explained, noting that since deployment there has been a significant increase in employee engagement scores.

Leveraging an AI-driven solution has also had a positive impact on performance in other areas.

Llewellyn highlighted the platform’s Precision Utilization Management function, which allows Coordinated Care to better track its performance using inpatient status scores and the associated reporting functionalities.

Schardt echoed this sentiment, noting that the AI’s reporting allows MultiCare to generate a wealth of data that provide performance insights.

“We have multiple [key performance indicators] that aren't necessarily associated with the platform, but I will tell you that the reporting out of [the platform] is so robust that we actually have a data analyst that takes the reporting,” Schardt explained.

MultiCare uses the platform to measure how many reviews have been conducted, the time in which the reviews are conducted, conversion rates, physician advisor reports, and the number of cases reviewed, among other metrics.

PUTTING PROVIDERS AND PAYERS ON THE SAME PAGE

KPIs are critical from a business and compliance standpoint, but Schardt and Llewellyn also noted that these improvements had bolstered both organizations’ ability to help patients and beneficiaries by putting payers and providers on the same page.

MultiCare and Coordinated Care have leveraged the platform to improve their ability to communicate and collaborate effectively with one another to improve patient and beneficiary experience.

“[Since deploying the platform,] our relationship with MultiCare has gotten a lot closer, and it’s become a good working relationship,” Llewellyn explained. “We work collaboratively, and it feels like we’re on the same team, even when we step away from the table. This makes communicating with each other so much easier because we’ve set everything up to run seamlessly. When things are missing on either side, they’re escalated and addressed quickly, and all our authorizations can go through in a timely manner.”

For MultiCare, the benefits include not only improving patient experience but also reducing administrative burden.

“When we're working with a payer that is also on the same platform, [if we can] all agree on the status of the patient in a certain acuity for services being rendered, we don't have to have continuous conversations about those patients,” Schardt noted. “Instead of every case, every day, there are some cases that only need to be reviewed once, everybody agrees, and we move on to the high-risk cases. So, it's made the administrative burden on both sides a little bit less, which is really nice.”

The benefits of this improved communication and collaboration are then translated into financial and care benefits for patients, Llewellyn and Schardt stated.

According to Schardt, ensuring that patients get the care they need at the right time and at the right level is a top priority for all parties, and leveraging an AI-backed solution can support that goal.

“What's nice about this particular platform is we want to ensure that the services being utilized from a provider perspective are reimbursed,” she explained. “We want the reimbursement for the services being rendered, and the payer wants to make sure that the services being utilized are appropriate and appropriate for reimbursement. The CORTEX platform has put us both on the same page with that.”

“This way,” Schardt continued, “the patient is only financially held responsible for the correct portion of what they should be. So, when the payer and the provider are both on the same page, and we both come out with the same outcome, then the beneficiary benefits from that as well. Then, they aren't in between the need of paying a co-pay or out of pocket, [which] may be disputable.”

She further explained that the patient benefits aren’t purely financial but also relate to patient access to accurate information.

“I think what we have to understand is there are multiple other complexities with utilization review, and one piece of that is the right forms,” Schardt said. “So, a particular status for a particular payer in a line of business requires a certain form to go to the beneficiary so that they're aware of their rights under that status. [This] does tie in financially, but I don't want to focus on just the fact that the beneficiary is held responsible for the correct financial keys, but they're also getting all the benefits of all the rights that they are owed, [such as] getting the right information.”

As healthcare becomes more complex, the need for improved collaboration between providers and payers will become increasingly important.

“Looking at the bigger picture, electronic medical records are the future, so allowing everyone to see what’s going on from either side is going to be crucial,” she stated. “Payers and providers being able to exchange that information effectively and efficiently will ultimately benefit the level of patient care, and that’s really what we’re all focused on.”