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 Admissions Utilization Review 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 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.]

How It’s Being Used ED Admissions Weekend Admissions Critical Access Hospital Utilization Care Transition and Readmission Ambulatory and Procedural Admissions

Example Use Case Weekend Admissions

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? [EXAMPLE] Time getting Monday morning staff up to speed 30 minutes per patient Resources looking up documentation after the fact Lost reimbursement revenue due to inappropriate admission $12,000 X 5 patients = 2.5 hours X 5 patients = 2.5 hours X 5 bed days $60,000 =

What Are the Costs Over the Course of One Weekend? [Fill in your own estimates here] Time getting Monday morning staff up to speed [How many hours/minutes do you spend per patient?] Resources looking up documentation after the fact Lost reimbursement revenue due to inappropriate admission [Average cost per bed day] X # patients = X hours X # patients = X hours X # bed days $X =

Selection Criteria: How Indicia Stacks Up Ease of use Guidelines lookup and search by any staff member Clarity of indications Visual indications for admission Effective use of time PDF, save or print the guideline for case manager review on Monday

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]