Community Health Solutions Makes the Most of Every Healthcare Dollar

Community Health Solutions of America (CHS) is a nationally recognized provider of innovative and comprehensive medical care management services for a diverse client base serving more than 200,000 covered lives. Utilizing the expertise of its team of physicians, nurses, social workers, and healthcare analysts, CHS develops and manages Primary Care Case Management programs for State Medicaid entities. CHS also makes available specialized programs for Medically Complex Children and Adults. As a provider of care management services, CHS offers holistic Care Coordination (case management); Care Education (disease management/health education); Care Oversight (pre-certification/prior authorization); Care Support (24-hour nurse line); Network Development and Maintenance (contracting, credentialing, HEDIS and utilization monitoring and reporting, and value-based financial incentives); and Member/Provider Relations.

Prior to July, 2013, CHS experienced a rejection rate that represented significantly less than 1% of the total number of claims received for pre-processing. This low rejection rate was due to the fact that the tools that CHS had at its disposal weren’t providing the guidelines and visibility staff needed during the pre-certification/prior authorization process. Without a stricter tie to evidence-based guidelines in the pre-processing stage, there was inconsistency in the medical care that was authorized and limited assurance that healthcare dollars were being directed in the most efficient way.

Making the Switch

To more fully align nurse reviewers with the evidence-based decision-making tools needed to make appropriate medical necessity determinations, CHS switched in July, 2013 from another large clinical criteria provider to McKesson’s InterQual Criteria. The improvements they saw were dramatic and almost immediate. A senior vice president of care management at CHS said, “Prior to the switch, our rejection rate was less than 1%. InterQual accessed via CareEnhance Review Manager provided us with much more specific criteria and lessened the chance that those criteria could be circumvented.” The value of the switch quickly became clear. From a less than 1% rejection rate, CHS’ rejection rate by nurses has risen to approximately 12% and the rejection rate of cases that receive physician review has risen to approximately 4%.

Using the rich clinical detail that InterQual Criteria provides, CHS increased its ability to assess the clinical appropriateness of patient services by placing patients within the context of a wide array of factors, including severity of illness, comorbidities and complications, and the intensity of services being delivered. CHS chose to access InterQual Criteria using CareEnhance Review Manager Enterprise, which delivers InterQual Criteria via browser-based technology, enabling easy, accurate communication among care providers and care managers. As a result of easy access to patient-specific criteria, CHS was able to align its members with the most appropriate level of care. As an executive vice president at CHS said, “Many of the [previous vendor’s] criteria were generalized and couldn’t be associated with the specific values needed to gain an in-depth understanding of the individual patient. InterQual Criteria are much more granular, providing us with the specific, evidence-based insight we need to help ensure that the appropriate care decisions are made.”

The InterQual Criteria are formulated by combining systematic, critical assessment of the medical literature by a highly trained InterQual Clinical Development Team with feedback from an InterQual Clinical Panel of hundreds of experts.  A CHS utilization management supervisor described the level of specificity she has come to associate with the InterQual Criteria: “Prior to implementing InterQual Criteria we would often see patients listed as having ‘respiratory distress.’ While that was an accurate description of the patient’s condition in general, it didn’t give us a clear view into the experience of that specific patient. As a result, we didn’t have the evidence we needed to help steer that patient to the most appropriate care. By contrast, InterQual breaks out respiratory distress into age categories and associates those categories with specific respiration rates. It also makes clear what information the hospital should provide and what tests should have been done. That level of detail gives us the evidence we need to make an informed decision about whether to qualify that patient for an inpatient level of care or seek secondary review to ensure that appropriate care is provided.” When review is required, CareEnhance Review Manager Enterprise helps automate the care review process, retrieve data, aggregate reporting, and electronically share medical necessity reviews along with the additional patient information required for the review.

Download the full case study here (PDF, 114 KB).