Unlocking Potential - UM Staffing Strategies for Success

Unlocking potential is a key theme for talent and human resources leaders. Employees are often brought into an organization with the skills and knowledge necessary to do their jobs well, but their full potential is rarely recognized during interviews or beyond.

Incorporating UM into the hospital review process can help with cost reductions and patient satisfaction. But UM can be challenging to implement and manage, particularly in the face of staffing limitations.
1. Focus on Retention

Many factors contribute to high turnover in the healthcare industry, but one of the most important is finding ways to keep staff members happy and engaged. This can be accomplished through employee rewards, benefits packages and workplace culture. It is also possible to recruit with retention in mind, by ensuring that the job description and recruitment strategy align with what employees want.

For example, UM programs have a high turnover rate for nurses, which may be because of a lack of training and support opportunities, or because the work is not interesting enough. Focusing on retaining nurses and other staff members will help your hospital find and retain the best talent.

Another way to improve staffing is to make sure that the UM process aligns with the hospital’s goals and priorities. The hospital needs to ensure that the program is working toward reducing unnecessary utilization, increasing efficiency and improving patient outcomes. It is important to have a clear vision for the program, and communicate this to everyone in the organization.

Hospitals need to ensure that the UM process meets national standards set by URAC (Utilization Review and Quality Assurance). These include requirements for a clinical decision-support system, data collection and reporting, and the use of clinical guidelines and medical reviews.

The National Academy of Medicine’s former Committee on Utilization Management by Third Parties found that providers often experience dissatisfaction with UM. They are concerned about the “hassle factor” of justifying admissions, length of stay and procedures to UM companies over the phone, arguing about medically necessary care with different teams of UM experts, and complying with proprietary clinical rules.

To avoid this, a UM program should be adapted to meet the needs of both the medical community and the insurance industry. For instance, by providing more educational and training opportunities for physicians, the program can shift from a regulatory function to one that enhances the value of treatment. This will make it more acceptable to both patients and physicians. Additionally, the development of electronic connectivity between payers and providers will reduce the need for a prospective case-level review of every service. https://umgcllc.com/staffing/
2. Invest in a UM Review Tool

UM is a critical component of any self-insured employer's cost-control efforts. While some employees may view UM as a tool used by insurance companies to deny coverage for expensive tests or treatments, the goal of UM is to prevent unnecessary medical care by ensuring that any treatment recommended meets the guidelines set forth by a health plan.

Whether you're a large employer or small business, developing a strong UM program can help you manage costs and improve employee satisfaction. However, staffing your UM team for success requires an understanding of the process involved in prospective, concurrent, and retrospective reviews. You'll also need to be aware of specific state and federal guidelines for reviewing patient eligibility, including Medicare and third-party payer requirements (e.g., ERISA, Medicare Access and CHIP Reauthorization Act, and HIPAA).

In the past, the use of UM in hospital settings has been associated with a reduction in the number of days spent in hospital beds and a reduced rate of hospital cost increases. However, there is currently little evidence that UM has had similar effects on other areas of the health system or that the use of UM as a whole has reduced overall health care costs.

Traditional UM processes require that physicians submit requests for care to payers and that payers review each request based on medical necessity, network guidelines and reimbursement rules. These processes can be time consuming and frustrating for both physician and payer. In addition, they often fail to deliver the rich data that can be shared between payer and provider in order to develop improved policies and high performing networks.

As a result, many providers have been dissatisfied with the use of UM. They have expressed concern about the "hassle factor" of being required to justify admissions, length of stay and procedures to UM staff, about having their requests denied and about the need to comply with a variety of different sets of proprietary clinical guidelines (Institute of Medicine Committee on Utilization Management by Third Parties, 1989). As a result, many doctors feel that UM is an adversarial process that interferes with professional autonomy and can be counterproductive to efforts to control health care costs.
3. Be Flexible

Having the right staffing mix helps ensure that your company can take advantage of opportunities quickly and efficiently. It can also help you stay ahead of changes in the marketplace, customer needs and industry regulations. For example, if there is an outbreak of COVID-19 or another public health crisis, you can use a flexible workforce to meet the extra demands without adding significant costs to your bottom line.

The same flexibility that can benefit UM programs can also help you keep up with other changes in the workplace, including shifting business priorities and new technology. For instance, the National Committee for Quality Assurance (NCQA) now offers a set of standards that can help you develop and manage an effective UM program. It’s important to note, however, that these new standards are not intended to replace existing state and federal requirements or guidelines for UM.

Achieving a successful UM program will take time and effort, and a strong understanding of how your organization can implement changes to improve efficiency and cost control. For example, you may need to update records systems and processes. You will also need to ensure that your UM program complies with state and federal insurance guidelines. In addition, a robust UM program will likely require you to establish and maintain relationships with recovery audit contractors and other third parties to review claims and identify underpayments for Medicare and Medicaid.

In a fee-for-service payment system, excessive and unnecessary care can be costly to the healthcare system. Extensive literature suggests that perhaps 10 to 30 percent of diagnostic tests, procedures and hospital admissions are unnecessary (Chassin et al., 1987; Greenspan et al., 1988; Siu et al., 1986; Winslow et al., 1988a; and Winslow et al., 1987b).

Trying to control unnecessary utilization with traditional methods over the telephone is complex and expensive for physicians. Moreover, such efforts can be countered by increases in utilization in other non-regulated areas (Schwartz and Mendelson, 1991). Fortunately, advances in electronic connectivity between providers and payers make it possible to rapidly and efficiently perform many UM tasks, including hospital precertification.
4. Create a Culture of Success

The modern workforce expects a company culture that aligns with the values of their personal beliefs. Employees who work in an environment that doesn’t promote a positive culture are likely to find themselves seeking employment elsewhere. The costs associated with this turnover are severe, costing companies up to twice an employee’s annual salary.

Organizations can create a culture of success by offering a comprehensive rewards package that includes competitive salaries and opportunities for professional growth and development. Culture can also be shaped by the ways that managers interact with their teams and the overall work practices of the company. In addition to monetary compensation, organizations should strive to build a culture of accountability and learning, respect, diversity, and integrity.

UM is a complex set of processes and procedures that requires collaboration between a variety of entities, including nurses and doctors at all levels of training, hospital staff (ranging from small town clinics to well-known facilities like Mayo Clinic), insurance companies, and national health organizations. In many cases, these multiple parties have conflicting objectives that must be aligned to ensure a successful UM program.

Managed care companies seek to control utilization by limiting the amount of time patients spend in hospital beds and reducing their total health care expenditures. Providers, on the other hand, often see UM as an attempt to limit their professional autonomy and income. This has been a significant barrier to achieving UM goals, even with the benefits of advanced information technology and clinical guidelines.

To overcome this challenge, managed care companies are beginning to recognize that a culture of mutual respect and cooperation is necessary for a successful UM program. Some have begun to decentralize their operations in order to foster relationships with local providers and focus on developing a shared understanding of the needs of both parties. They are also working to develop strategies that reduce the need for review by identifying and selecting providers who practice high quality, efficient care that results in fewer claims for medical necessity reviews. This approach can be more effective than the current model of hospital-level review that has been in place for many years.