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INDICIATM FOR UTILIZATION REVIEW
Build your business case
Created by Milliman Care Guidelines
For hospital decision-making teams
How to Use This Resource
• If your organization is considering Indicia for Utilization Review, you may have other team members who are less familiar with the product
• We have designed this PowerPoint deck so that you may customize it or use any of its assets in presentations to your team
A Word About Content Rights
• We’ve left these slides editable so they can be easily used
• Once you have adapted the deck, however, we can no longer be responsible for the validity or accuracy of its content
• The names Milliman Care Guidelines and Indicia are trademarks of Milliman Care Guidelines and screenshots of our products are the property of Milliman Care Guidelines
Indicia for Utilization Review
• Designed for providers
• Contains the most thoroughly researched, most broadly used care guidelines in the industry
• iPad enabled
• Supports utilization review efforts
• Helps avoid inappropriate admissions
Tackles Practical Needs
• Easy to look up and interpret criteria
• Streamlined user experience for any member of the care team – triage nurse or ED physician alike
• Visual go/no-go indication
• Mobile access for iPad
Admissions Utilization Review
• PDF, save and print capabilities
• Automated admission/discharge indications across various care settings
• Can integrate with existing case management or EMR software
• Internet-like search capabilities
How Indicia would benefit us
• Helps ensure focus on patients’ path to health
• Supports existing workflow
• Helps achieve reimbursement and care management goals
• Facilitates conversations with payors about appropriate care
Our Organization’s UR Challenges
• [What challenges are you experiencing with regard to your existing UR process? Place those here.]
Our Plans for Indicia Include
• [If you have specific goals or business needs that could be addressed by using Indicia for Utilization Review, include those here.]
What Happens in Our Organization at Night or on a Weekend?• Who is responsible for making judgment calls about
admission?
• Are admissions handled consistently and in accordance with the most up to date, valid criteria used by our payors and CMS?
• Is the patient receiving the appropriate level of care?
• How is that decision documented?
• How is the case manager brought up to speed Monday morning?
• How can we ensure we will be reimbursed for this care?
What Are the Costs Over the Course of One Weekend?
X 5 patients
=
=
X 5 bed days
=
X 5 patients
2.5 hours
2.5 hours
$60,000
[EXAMPLE]
What Are the Costs Over the Course of One Weekend?
X # patients
=
=
X # bed days
=
X # patients
X hours
X hours
$X
[Fill in your own estimates here]
Let’s Walk Through a Typical Admission
• A patient presents to the Emergency Department in some respiratory distress
• Given the patient's condition the admitting physician thinks she should admit him
• The triage nurse is responsible for determining the appropriateness of the admission according to the evidence
Easy Guideline Lookup
The Triage Nurse looks up the criteria for hospital admission for a patient with acute exacerbation of Asthma on her iPad.
Clear Indication for Admission
The Triage Nurse documents the symptoms and a yellow bar indicates the patient does not need to be admitted.
Quick Documentation
The Triage Nurse then views indications for Observation Care, determines he’s a good fit, and documents her decision for the Case Manager by saving a copy of the indications to her department’s shared drive.
How will Indicia Benefit Our Organization?
• Promoting evidence-based clinical decisions
• Improving documentation for utilization review
• Improving reimbursement rates by using the same, evidence based best practices used by our health plans
• Reducing staff time by x% and saving up to $x in inappropriate admission costs [insert your own figures here]
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