Change Management and Denials Reduction

By: Edwin A. Espiritu, MSN, RN, ACM-RN, CCM

Change management in utilization management (UM) requires a strategic process of preparing, supporting, and guiding healthcare organizations through changes to UM processes, policies, and technologies to ensure smooth adoption, improve patient care, and achieve efficiency and financial goals. Key elements include comprehensive planning, engaging stakeholders, clear communication, managing resistance, providing training and support, and continuously monitoring and evaluating the impact of the changes to ensure long-term success and sustained positive outcomes.
Why Change Management is Crucial for Utilization Management

  • Embracing Healthcare Transformation: Navigate the shifting healthcare system, respond to the modern health environment, and adapt to the digital health era. Staying relevant and effective in a rapidly evolving healthcare landscape driven by new policies, technologies, and the shift to value-based models.
  • Enhancing Efficiency and Outcomes: Orchestrating a strategic shift streamlines workflows, reduces costs, and improves patient outcomes by ensuring the right care is delivered at the right time.
  • Driving change management and fostering buy-in: Change is often met with resistance from staff. A strong change management strategy helps address these challenges, building organizational capacity for change and ensuring new initiatives are adopted and sustained.

The key components to success include:

  1. Strategic Framework: Developing a clear vision for the change, identifying goals, and creating a strategic plan for implementation. - The core features or fundamental factors include utilization review (prospective, concurrent, and retrospective), risk management, and quality assurance, all supported by interdisciplinary teamwork and evidence-based clinical guidelines.
  2. Stakeholder Engagement: Involving all relevant parties in the change process to build consensus and foster buy-in.
  3. Effective Communication: Articulating the vision, rationale, and benefits of the change through clear, consistent, and honest communication to all stakeholders.
  4. Overcoming Resistance: Understanding the psychological impact of change on individuals and implementing strategies to address concerns, provide support, and overcome pushback.
  5. Training and Support: Providing necessary training, tools, and ongoing support to help individuals adopt new behaviors and processes.
  6. Program Review and Impact Analysis: Establishing key performance indicators (KPIs) to track progress, measure the impact of the changes, and make data-driven adjustments to the strategy as needed.
  7. Cultural Adaptation: Fostering a culture that is open to change and aligns with the ultimate goals of the initiative, such as enhanced patient safety and value-based care.

 

Denials reduction involves a proactive and systematic process in healthcare revenue cycle management focused on preventing and minimizing claim rejections by payers to improve cash flow and financial health. Key strategies include strengthening front-end processes like patient registration and pre-authorization, implementing automated claims scrubbing, establishing a denial task force to identify root causes, enhancing documentation, analyzing trends, and optimizing appeals workflows.

The impact on reimbursement whenever a claim has been denied can lead to financial losses for healthcare providers, and increased administrative burden. Some of the work that I have implemented and developed, especially the standardization of processes and flowcharts (see screenshots below), help mitigate or prevent hospital denials. Additionally, it helped guide our utilization review nurses and maintained the standard process established.

 

It is important to note that workflows may not apply from one organization to another without a good understanding of your own processes.

 

The workflows and flowcharts are just one of the many steps needed. Putting into an actionable plan and integrating with technology is the harder piece of the puzzle, which includes developing operational reports. 


To better understand what an Operational Report is. An Operational Report is a real-time or near-real-time document or dashboard that delivers detailed insights into an organization’s daily activities and short-term performance, which helps monitor operations, identify issues, and make quick, tactical decisions to improve efficiency. This focuses on "what's happening now" and uses granular data to track metrics such as production output, resource utilization, costs, and performance to guide day-to-day management. Some of the operational reports I have created includes data visualization as shown on the screenshot below.

 

The use of color as a visual cue to represent data, enhances clarity, and helps our users quickly understand patterns and priorities.

Partnering and having the support of the organization’s EPIC team also helped us achieve and develop the Utilization Management dashboard, which is interactive and has the ability to drill down to the patient level. It is paramount to understand that the dashboard you need to create is of significance to the organization’s priorities or needs.

However, this path has been anything but easy. The challenges and setbacks did not deter me from the “Pursuit of Perfection.” Faced with grueling hours and moments of profound doubt, but the outcome was rewarding and basic foundation established.


My in-depth background in Case Management and Utilization Management is strengthened by report writing skills. This combination highlights my comprehensive professional skill set for healthcare, focusing on efficient resource management and quality patient outcomes through strong documentation.


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