PGodfrey_Automation of Utilization Management

Running Head: UTILIZATION MANAGEMENT AUTOMATION
Utilization Management Automation for Care Management Organization.
Paul Godfrey, MBA, BSN, RN, MSN Candidate
Rutgers University, Newark NJ
School of Nursing
NINF5405: Advanced Practice in Nursing Informatics
Faculty Advisor: Rose P. Estrada, DNP, RN, BC, CPN
Preceptor: Deidra Brown, RN, MSN, NP
Facility/Address: Montefiore Care Management, 200 Corporate Blvd, Yonkers, NY 10701
April 1, 2015

UTILIZATION MANAGEMENT AUTOMATION 1
Abstract
Utilization management is sometimes not given a high level of priority in the cycle of
patient care but could hinder the progression of care when not managed properly. The turnaround
time between service request and approval or denial is crucial in an emergency situations and
automating the system could greatly impact the time interval. When an inpatient facility is an out
of network facility and unrelated to the care management organization, before inpatient
hospitalization information is communicated to the care management, the patient may be re-
hospitalized and lack proper follow up. One trigger for outpatient follow up utilization activity is
inpatient activation notification. Approval process cannot be completed until all required
information is received by the payer or payer representative. Some payers have contract with
care management organization that are responsible for authoring or denying care requests.
The business of health care is complicated but the end result is health of the patient. The
process must be synchronized and all parties involved in authoring service and caring for the
patient must have an effective communication strategy to facilitate best health outcome for the
patient. Disjoint and uncoordinated system of communication will lead to silo process and
becomes an impediment to the utmost health outcome of the patient. When collaboration
between care coordinators and care facilities is encouraged and implemented, all entities will
work effectively for the patient.

Project Description
Automation of utilization management improves patient outcome. As patients discharge
from inpatient care management to the community, there has to be a better process of notifying
care coordinators who could follow through with outpatient appointments. In cases where
inpatient information is not shared with external care coordinators, the turnaround time between
notifications could be precious and sometimes contribute to re-hospitalization which increases
cost of care and unhealthy condition for the patient. Another important issue is the process of
approving care request with greater emphasis on patients requesting outpatient care and waiting
extended time for communication from the payer. Most of the communications with the
utilization management entities are through the phone system but if automation is provided
where patients/members can access the system of use and request a service which should be
channeled to a work queue, this will reduce turnaround time between service request and
response.
At Montefiore CMO, a legacy system called CCMS is used for utilization management.
Some of the processes involved in utilization management using CCMS are not automated,
thereby not effective in facilitating faster care management for the members. Epic tapestry is
being implemented to replace CCMS utilization management for Montefiore CMO. Emphasis is
on functional requirement which CMO would anticipate to be part of the Epic tapestry solution.
Project Scope
The scope of this project will highlight the expected functional requirements and how
they would help to foster a more effective utilization management. Emphasis will also be on
transitioning to a new approach with respect to educating the staff, members, and providers on
how to utilize an improved automated process to improve the workflow. This project will

include analysis of Inpatient and Outpatient Utilization Management. The scope will also include
providing insight into the relationship between effective utilization management and optimum
patient health outcome. The culmination of analysis in this project will lead to contrast the
present CMO utilization management with a legacy system called CCMS and a new system
called EPIC Tapestry with emphasis on the Montefiore CMO functional requirements. Finally,
care continuity relationship with automated utilization management will be explored. Improved
system must be utilized to yield expected result and to this end, educating the Montefiore CMO
staff and providers on how to utilize an improved automated process to improve the workflow
geared toward member care management will be the ultimate goal of the Montefiore Center for
Innovation and Learning
Project Goal and Purpose
Utilization management involves patients, care providers, and payers. Show how
automation of the process of utilization management can help to improve care outcome. When
the patient, care provider and payer can communication effectively, the ultimate result will be
best outcome for the patient and cost saving for the payer and thereby allowing the care provider
to reach more patients. Using the concept of distributed system to provide utilization
management will allow care management entities, members to be served, and service providers
to communicate effectively and foster faster turnaround time between service request and service
provision.
Institute for Healthcare Improvement (IHI) qualifies the effective management of health
care utilization with the concept of Triple Aim, which entails population health improvement,
enhancing the patient experience of care with respect to quality, access, and reliability, and
finally reducing or at least making effort to control the per capita cost of care. (Cornett, 2012,

p13). Waste and abuse could also be reduced when information about health care utilization
could be shared between service providers.
Project Objectives
Utilization Management (UM) allows for managing health care costs by evaluating
authorization requests for services and procedures. Requests from providers must be handled by
applying CMO and health plan requirements in a manner that is correct, fair and uniform. Rules
can differ greatly among health plans and lines of business. Authorized services must be aligned
with the member’s benefit coverage, and where possible, services should be directed to in-
network providers.
UM is an area subject to periodic health plan audits. Documentation of proper steps and
outcomes is crucial. Staff needs to be guided as much as possible to ensure both quality and
quantity are being achieved. There are regulatory requirements for the amount of time a health
plan has to respond to a request.
Problem identification and Assessment
CMO receives preauthorization requests from various sources, for example, an
application called Post-n-Track, telephone, fax, and mail. If an authorization was submitted via
an external source like Post-n-Track, the system will create the authorization in real time with a
distinct authorization number and record the source of the request. In order to create an
authorization, a core set of mandatory data fields must be entered and validated. The system
must provide the ability to configure and employ required data validation checks upon saving an
authorization. The system must also take the appropriate action upon failure of a data validation
check. The authorization should only be created if all of the specified validation checks succeed
and if all of the required data fields are present.

The authorization intake process must also accommodate requests when a member and/or
provider are not present in system at the time the request is received. The system must support
workflow to facilitate the research and resolution of provider and member issues as well as
support the correction of the request with the correct provider and member records. The current
manual workflow needs to be automated where possible.
Currently, the legacy system does not provide sufficient validation, nor does it enable the
user to complete entering requests expeditiously. The system does not provide the ability to
configure application-based validation logic that checks for correct and meaningful data.
Additionally, the system does not provide the ability to derive or filter lists based on the data
entered on the authorization.
Stakeholders and Organizational Culture
CMO’s strategic goals are focused on achieving success in several programs that are
closely tied to national health care reform efforts. To maintain consistency and alignment with
the Montefiore Medical Center, the goals are divided among four areas—Innovation and
Learning, Improve Internal Processes, Customer’s View and Finance and Growth.
The CMO has taken the lead in Montefiore’s participation in two of the most important
health care reform programs of the Patient Protection and Affordable Care Act: the Pioneer
Accountable Care Organization initiative of the Center for Medicare & Medicaid Innovation and
the Health Home program of the New York State Department of Health.
While the programs deal with different populations (Pioneer with Medicare fee-for-
service beneficiaries and Health Homes with Medicaid beneficiaries), the central elements of
both involve care coordination of patients with chronic conditions, especially those with high
cost and complex cases.

The major stakeholders for this project within Montefiore organization are CMO-MIS,
Montefiore-MIT, CMO-DAR, CMO-CMPE, CMO-CLI. The technical stakeholder is
Montefiore-MIT, the reporting and analysis stakeholder is the CMO-DAR, The business
requirement stakeholder is the CMO-CMPE and the clinical training and knowledge transfer
stakeholder is the CMO-CLI. External vendors are interviewed and invited for deep dive sessions
with the hope of signing a contract. EPIC application has been identified as the most probably
application to replace the legacy CCMS in performing utilization management functionalities of
Montefiore-CMO.
Project Executing Process
The final project sign off is performed by the senior management of Montefiore and the
vendor senior executives. Each functional requirement is signed part of the approval process.
Each department providing any aspect of the functional requirement obtains a signed copy by
each department senior director. The work breakdown structure contained within the project
schedule is approved and signed by each lead senior director. Collectively, all signed
components are signed by the Montefiore senior executive and countersigned by the vendor
senior executive before implementation.
Project Monitoring
Weekly update meetings are scheduled to discuss the progress of the development team
and answer any question that may arise. Montefiore has dedicated in-house Epic teams who were
sent to training at the Epic headquarters and became the liaison between Epic and Montefiore
organization. This allows for constant monitoring of the development team. Testing is
performed as a component of the whole system is completed. This helps to identify errors which
could derail the lunching of the system if not corrected.

AS-IS Workflow

To-Be Workflow

Project Plan
Gido and Clement (2012) explained that “It is necessary to lay out a roadmap, or game
plan, that shows how the project scope will be accomplished within budget and on a schedule”
(p11). The triple constraints of a project are scope, time and budget and if one aspect is affected,
there will be a deviation of project plan. The general plan of this project is handled by
Montefiore MIT. The problem identification involves the subject matter experts from the CMO-
MIS, CMO-DAR, CMO-CMPE, and the utilization management staff across the CMO NCM and
CMO-UBA. The training and knowledge transfer to existing and new staff is under the
leadership of the CMO-CLI department. The identification of external vendor is under the final
sign off of Montefiore senior leadership. The automation of utilization management is viewed as
crossing many functional departments of Montefiore but CMO UM department handles the
intricate of authorization and denials. They are viewed as the subject matter experts in the area of
Inpatient and Outpatient utilization management process with respect to member s enrolled in
care management program of Montefiore.
The Montefiore MIT is the highly technical team that will initiate the functional
requirement related to infrastructure. Questions like connectivity issue, reliability of servers,
sharing of information, backup capabilities, and system architecture. The CMO-DAR is
responsible for identifying reports to be derived from the system. They will come up with
functional requirements that will cover all the operational and clinical reports needed by each
department. The functional requirement in this area will seek to make sure that the Utilization
Management Application will draw inference from internal and external data sources to produce
all needed reports. The CMO NCM and CMO UBA are the subject matter experts and are
closely familiar with how the users will interact with the system to derive expected results. The

business requirement documentation is tasked with collecting all the functional requirements and
a major component of this document is user interface, attributes, task attribute, rules engine
functionality, collecting questionnaire from users, drafting the as-is workflow and the to-be
workflow, and interacting with selected vendor for deep-dive sessions. The CMPE team
coordinates the activities of CMO NCM and CMO UBA by leading and organizing meeting
sessions.
A major component of the project plan is scheduling user training post implementation.
The CMO-CLI is tasked with documenting training materials. They will be responsible for
assessing the skill levels of the staff and determine the extent of training needed to bring the staff
to productivity level with the new system. The legacy system functions with manual task and
external local file whereas the new system will have automated task and ability to trigger tasks
using rules engine. The staff has to understand how to use the task system and disposition each
appropriately.
Human Resource Management
Montefiore has implemented a hiring freeze which may make human resource
management more dire than previously anticipated. One of the most important aspects of a
project is using the right people for the right task. As employees change positions within and
outside the organization, it is imperative to backup list of capable staff to utilize when needed.
The concept of having dedicated staff for Epic under Montefiore has provided a great human
resource management strategy which will help to see the completion of the project. The hiring
freeze did not have an impact because dedicated staff have been committed and trained for this
project.

Project Schedule and timeline

Project Cost Analysis (Tangible and intangible Benefits)
Within any project, different aspects of cost estimates are performed, for example
aggregated total cost, budgeted cost, cumulated cost, actual cost, committed costs, earned value,
a cost performance index, cost variance, and a cost forecast (Gido & Clement , 2012, p261). As
part of a larger organizational information technology project, the utilization Management
Application is embedded within the Epic System. Tapestry is the Epic system component

designed for utilization management and Montefiore is leaning towards using Epic for this
solution.
Montefiore is making effort to comply with meaningful use requirement of the
Affordable Care Act. Towards this goal, there is a bundle of Epic Application which Montefiore
is presently implementing, for example Inpatient, Ambulatory, Tapestry, etc. The tangible cost of
the utilization management is part of the total contract between Epic and Montefiore. The
intangible benefits are faster turnaround time between member service request and response,
ability for the users to have a rules engine which will drive task assignment, ability for the
system to schedule call task and enabling the user to document call outcomes.
Project Quality Management
The provided functional requirement serves as a yardstick used as benchmark for quality
measures. All completed components of the system are tested based on the provided
requirements. Test cases are developed for different levels of the test team. All errors are
documented and submitted to the development team for correction. Some of the quality control
techniques used in project management are Cause and Effect Diagrams, Control Charts, Flow-
Charting, Histogram, Pareto Chart and Pareto Analysis, Run Charts, Scatter Diagrams, Statistical
Sampling, and Inspection (http://www.brighthubpm.com).
Project Risk
There is inherent risk of development taking longer time than approved. The utilization
management system is a subsystem of the automation effort and the resource allocation may not
be enough to deliver this portion of the system at the previously approved time. Changes in
provider policy which governs utilization management could add a layer of delay to the

development as new policies are implemented. Authorization and denial process differs from one
provider to another and could also complicate the utilization automation effort.
Project Communication
Web enhanced communication mechanisms are used to arrange and hold meetings
involving major stakeholders on a weekly basis. All participants connect using their personal
computer and telephone. All stakeholders are encouraged call others on a regular basis and keep
the lines of communication open. Once a month, in-person meeting is held and all major
stakeholders are invited to discuss progress of the project and address any outstanding issues.
Project Reporting
The project plan update is circulated to all major stakeholders as part of the project
reporting effort. Each department receives updates related to their task. Within communication
through email, the reporting updates are included as attachments.
Ethical and legal considerations
The Montefiore legal department is responsible for reviewing all contracts for legal
implications. The scope of the utilization automation project is limited to receiving requests for
service and approving or denying the request. A major component of ethical consideration is to
understand the process and follow the guidelines provided by the payers otherwise called the
insurance company or government entity. The rules of approval are set, which covers number of
days to wait for additional information pending a request and clinical guideline for approval or
denying.

Analysis of project outcome and success
Epic was invited as part of the project implementation to interview all the Montefiore
Utilization Management subject matter experts. Functional requirements provided by Montefiore
MIS were reaffirmed by Epic in several meetings. The difference between an open architecture
and closed architecture is the ability to change system functionalities without incurring much
additional cost of ownership. The Epic implementation team spent a reasonable amount of time
to show Montefiore Utilization Management team how to apply the Montefiore CMO functional
requirement to corresponding Epic Tapestry functionality. Workarounds were discussed and
demonstrated. Where gaps exists between Epic functionality and Montefiore CMO functional
requirements, workarounds are introduced because Epic does not ascribe to customization
because of the resources needed and the closed architectural nature of their application.
The inpatient Montefiore application will be integrated with Epic Tapestry because all are
Epic applications. Using Epic solutions for both the inpatient and outpatient utilization
management makes it easy for all Montefiore care management members who have inpatient
admission within Montefiore network to be linked with the proper care manager. Care continuity
is greatly enhanced as a result of using the same system for both inpatient and outpatient. Delay
in authorization comes when a Montefiore care management member is hospitalized within an
out of network facility. A general practice that can help in this situation is the inclusion of
assessment process for all inpatient cases. Questions related to care management organization
responsible for a patient could be collected at admission. The process of sending notices can be
automated using communication platform which will upload such notices into the utilization
management application for quicker processing thus enhancing care continuity.

Task management system embedded within the Epic Tapestry will be used to allocate
tasks to a team of utilization management staff. They will be able to use a pull of centralized
available task to select cases of members to work on. This will be a great improvement from the
legacy CCMS system which uses notification only between users and has no task management to
be used for task assignment. Utilization management involves application of rules with time
sensitivity. Keeping track of how many calls must be made, how many letters must be sent, and
other mandated communication before denial of request is a daunting task. Requesting additional
information from facilities also involves call tasks and all communications must be documented
and used in appeal cases. Epic tapestry provides a repository of attributes where all needed
information will be stored and retrieved as needed within the approval or denial cycle.
The success of deploying Epic Tapestry for Montefiore utilization management will be
measured by how proficient the staff is able to use the system and achieve maximum output. To
this end, the Montefiore CMO-CLI is tasked with scheduling in-class training for all levels of
users. The first level of training performed by Epic is the train-the-trainer sessions. The group
selected for this training sessions are mainly the Montefiore CMO-CLI. They will in turn
schedule the super user training and run small classes enabling the super users to learn and
demonstrate understanding of the system by taking written test of contents taught.
There is a delay in schedule with respect to implementation of Epic Tapestry. Montefiore
system of utilization management is different from many facilities because there is the CMO sub
division of Montefiore that will handle outpatient scheduling and care coordination. Facilities
without a care management subdivision will naturally discharge a patient after inpatient car, this
reduces layers of complexity. Montefiore has to coordinate discharge from inpatient care with
CMO and this layer of complexity was different from what Epic is used. CMO is not a

department of Montefiore but an organization with all levels of management affiliated with
Montefiore. Epic has to find a way to provide a solution that will be effective and thus the delay
in implementation.
Conclusions
As assessment is performed and diagnoses are being established, there has to be approval
of service. If the process is inefficient and causes delay in approving needed health service, the
outcome may be life threatening or fatal. If service is performed but not approved, the service
provider may run the risk of using extraneous ways to collect money from the patient.
Sometimes, the patient may not be in the position to discuss such transactions or make payment.
Automation of utilization management will shorten the time it takes to approve a needed health
service and also provide a rule based task system which users can employ to drive activities
needed in the process of receiving and processing service requests. Cornett (2012) stated that
“UM is the evaluation of medical necessity, appropriateness, and efficiency of the use of health care
procedures and facilities.” (p16)
All care requests are scrutinized for medical necessity before approval. If requested treatment is
necessary and appropriate, then information must be submitted by the requesting facility in cases of
inpatient and facility not owned or affiliated with the care management company. A cohesive process
predicated upon automation will be very useful and improve the outcome of care by eliminates lengthy
approval processes. In outpatient approval process, the process is lengthier because the member has to
notify the care management organization in that outpatient care service is needed. The request will be
processed and coverage verified before process of medical necessity is triggered. An automated process
can allow the user/member to interact with the organization’s system and update coverage information if
needed before making a request for service. A system that allows members and facility to seamlessly
enter request and get result will no doubt eliminate delay and improve positive care outcome.

References
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Organizational Stewardship. Journal Of Health Care Compliance,14(5), 13-20.
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Gido, J., and Clement, J. P. (2012). Successful project management, Fifth Edition, South-Wester
Cengage Learning, Mason, Ohio
Harrison, P. L., Pope, J. E., Coberley, C. R., & Rula, E. Y. (2012). Evaluation of the
Relationship Between Individual Well-Being and Future Health Care Utilization and
Cost. Population Health Management, 15(6), 325-330. doi:10.1089/pop.2011.0089
http://www.brighthubpm.com/certification/72854-a-roundup-of-quality-control-tools-and-
techniques/, retrieved 3/25/2015
Maclure, M. (2005). Drug Insurance Utilization Management Policies and“Reference Pricing”:
An Illustrated Commentary on the Article by Vittorio Maio and Colleagues. Milbank
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