HealthVine Utilization Management
Utilization Management Department Plays Unique Role in Children's Health
Utilization management (UM, as it's known in shorthand) is a healthcare discipline with the mission of ensuring that patients receive medically necessary services at the appropriate level of care in a timely and efficient manner. UM is an established practice in managed care – but pediatric-focused UM departments are rare.
HealthVine moved quickly to stand up its Utilization Management Department by mid-2021. It recruited a team of committed individuals from various backgrounds – managed care, health plan operations, nursing, pediatrics, and children’s and adolescent behavioral health, among others – needed to take on this pioneering role.
The stakes are high in the realm of children’s health. The opportunity to model a highly specialized pediatric approach to utilization management is immeasurable.
What We Do
Not unlike other managed care organizations, CareSource selects specific services and therapies for coverage after review and approval by its UM staff or a delegate, such as HealthVine. Utilization management reviews weigh many factors: clinical documentation, medical necessity, evidence-based criteria, cost, potential outcomes and available alternatives.
The typical UM cycle starts when doctors and other healthcare providers submit service requests to a managed care organization, like CareSource, to approve coverage for medical, surgical, or behavioral health services, therapies, or durable medical equipment they intend to prescribe to a plan member.
As the CareSource delegate for UM, HealthVine’s pediatric experts at Cincinnati Children’s review submissions to confirm that they are medically necessary and notify the child’s providers if they are approved or denied. Denials cannot be issued unless they are reviewed and approved by Cincinnati Children’s pediatricians, specialists, and sub-specialists.
UM at HealthVine Up and Running in June 2021
In June 2021, HealthVine began receiving authorization requests electronically from CareSource for inpatient, outpatient, behavioral health services, genetic testing, durable medical equipment, dental anesthesia, home healthcare, and private duty nursing. HealthVine does not handle utilization management for advanced imaging services, routine dental care, or outpatient pharmacy for CareSource.
When HealthVine UM denies a service request, healthcare providers can ask for peer-to-peer meetings with Cincinnati Children’s HealthVine representatives and ask them to reconsider their decision. Those meetings often result in additional information from the requesting provider, which may lead HealthVine to reverse its decision and approve the requested service.
If the denial remains in place, the next step is an appeal, which is a review by a third-party physician who is independent of HealthVine.
CareSource and the Ohio Department of Medicaid set performance standards for HealthVine’s UM turnaround time. For example, HealthVine is contractually committed to responding to pre-service requests within ten days for non-urgent service requests and three days for urgent service requests. In some cases, reviews take place after children receive services, which are retrospectively reviewed within 30 days of receipt.
How We Do It
HealthVine purposely set up its Utilization Management program while keeping the needs of its child and young adult members in mind.
Requests are assigned to HealthVine clinical reviewers who have been equipped with extensive pediatric training and ongoing educational opportunities, which make them well suited to evaluate each case. For example, some HealthVine UM nurses have worked in pediatric inpatient care and complex care. Behavioral health specialists assess requests for behavioral health services, while another UM lead may have many years of experience in durable medical equipment needs.
The UM staff provide coverage 24-hours-a-day, seven-days-a-week, so requests are always handled promptly, and as a result, HealthVine has met or exceeded the service levels in its delegation agreement with CareSource.
True to the HealthVine values of continuous improvement, impact and collaboration, the HealthVine UM team:
- Meets weekly with the HealthVine Care Management team and refers cases of members and families who need more support and services.
- Reaches out frequently to requesting healthcare providers throughout Southwest Ohio to establish valuable working relationships in the review of cases and to support goals around reducing and preventing documentation gaps and treatment delays.
- Partners with Cincinnati Children’s experts to review, write and revise policies for Medicaid to help advance and support children’s health, individually and as a group.
UM at Work: Members and Families in Need
Utilization management is a function often invisible to members because their doctors submit service requests and appeal denials.
Still, UM can stretch beyond its role of interpreting managed care guidelines and mediating between doctors and healthcare payers. At HealthVine, UM leaders and staff advocate for children and their families and pursue innovative approaches wherever they can, as a few case examples show:
- A family with multiple children with a hereditary condition needed specialist care. Consulting with experts at Cincinnati Children’s, the UM team learned that the leading specialist was in California. HealthVine approved the out-of-network coverage, and the children and parents were able to travel to California for care.
- A member with a complex condition was discharged home over the weekend. The member needed around-the-clock care, but a single, working mother was the only person at home. HealthVine UM collaborated with the Care Management team to search for a private-duty nurse and approved the services needed to support the family. Without nursing care at home, the child might have returned to the hospital
Our Impact
Operational Excellence Ensures Timely Treatment
Utilization management departments are high-volume, high-intensity operations. Staffing, processes, and technology must support a seamless process of intake, review, decision-making, and communications. Thousands of requests for services flow in each month, and delays in children getting services could lead to poor outcomes.
HealthVine UM tracks several metrics for inpatient, outpatient and behavioral health services. As its operations got rolling, the number of requests to review climbed from 1,100 in June 2021 to more than 2,000 in Dec. 2021. In the seven months it operated in 2021, HealthVine UM handled a total of 12,001 cases.
Turnaround time is a crucial metric, as members are at times in immediate need of clinical services that require review and authorization from the team. The illustration shows the compliance level, in percentages, for each category of service requests across medical and behavioral health. “CD” stands for calendar days.
- For urgent pre-service requests, HealthVine replied to 100% of cases within the two calendar days CareSource requires between June and Dec. 2021.
- For non-urgent pre-service requests, HealthVine met the service level (replying within 10 calendar days) more than 99% of the time.
- For requests for inpatient admittance, HealthVine achieved its service level agreement between 96% and 99% each month.
It is important to note that performance improved as more staff came on board. And HealthVine is committed to exceeding performance standards. It strives to turn around requests in five days or less in non-urgent cases and 48 hours or less in urgent ones.
A third key metric for UM is denials. Fewer than 3% of inpatient and outpatient service requests were not approved. Behavioral health case denials were higher, with nearly 21% of cases not approved. This differential between medical and behavioral health denials has prompted a quality improvement project and review in partnership with the HealthVine Quality Improvement team. The illustration below shows the denial and approval rates (out of 100%) for each major case type.
Advocates for Policy Changes to Benefit Children
As a delegate, HealthVine follows medical and behavioral health policies established by CareSource. But when HealthVine identifies policies that its staff believes do not adequately support the children’s best interests, they advocate for change, as the following cases from the past year illustrate:
- Coverage for specialized car seats was frequently denied in the past. Such seats are needed, for example, by some children with autism or mobility restrictions created by diseases such as cerebral palsy. Advocacy by HealthVine reviewers resulted in the expansion of eligibility criteria for car seats for these children.
- HealthVine UM influenced changes to policies for speech therapy and enteral nutrition (liquid nutrition given by mouth or feeding tubes) that were based more on the needs of adults, not children. For example, guidelines for the approval of speech therapy failed to address the unique needs of children with developmental delays.
- In the past, only durable medical equipment (DME) companies could fill doctors’ orders for continuous glucose monitors for children with diabetes. However, those companies usually keep traditional business hours, which can make it difficult for working families to pick up the equipment. HealthVine advocated with CareSource policymakers that allowing pharmacies to dispense the monitors would make it more convenient for families and, as a result, potentially lower the number of children who end up in the emergency room and the hospital because they aren’t getting insulin as prescribed.
Where We are Going
The HealthVine UM department continues its momentum. In 2022, after just a year in operation, it sought and expects to earn National Committee for Quality Assurance (NCQA) certification.
It continues to research and advocate for policy changes that its expert staff believe will help children.
As the first pediatric UM department in Ohio, Cincinnati Children’s HealthVine expects to become more engaged with other children’s hospitals. They hope to leverage their mutual curiosity, learn from each other’s experiences, and are potentially interested in partnerships.
Being part of an organization committed to research and innovation, the HealthVine UM program will collaborate with its peers in other programs to continue to evaluate the effectiveness of efforts to prevent illness, identify conditions earlier, and advance better care and treatment.
“This is an opportunity for us to impact the care of more than 130,000 children and affect the dollars and cents that are spent on children’s healthcare. We have a tremendous opportunity to direct this money where it will be most effective and is needed most.”
Stacey Ishman, MD, MPH, medical director, HealthVine Utilization Management