A highly proactive concurrent review process is pivotal to your plan members getting clinically appropriate, cost-effective hospital care.

Inpatient hospital expenses are the third largest claims category for commercial health insurers, based on a recent study by America’s Health Insurance Plans. Average daily hospital charges in the U.S. hover above $2,000, according to data from the Kaiser Family Foundation.

This means inpatient care is a cost concern for self-insured employers, whether they have several hundred or tens of thousands of health plan members. To ensure members get the care they need — while also seeking ways to control hospital costs — most employers and benefits consultants build “concurrent review” into their benefits programs.

Concurrent review involves monitoring the status and progress of hospitalized members to ensure they receive high-quality care in the most clinically appropriate setting. An effective review process also can identify ways to avoid unnecessary costs, help members make steady progress toward a safe discharge, even reduce the risk of readmission.

Why your concurrent review model matters

For most employers, an insurance carrier conducts the concurrent review. In a typical approach, the carrier preapproves a set number of hospital days, based on the diagnosis. Beyond that, the employer may have little to no engagement with the member or the care team unless a hospital stay extends beyond the approved length.

This hands-off approach can miss opportunities to avoid unnecessary tests or services, to “step down” care to a less costly but still clinically appropriate level, or to arrange home-based services that can prevent an extended hospitalization.

Quantum Health’s daily concurrent review process is integrated into our core consumer healthcare navigation and care coordination solution. We assign a nurse who engages one-on-one with the member before, during and well after a hospital stay. Our nurses and medical directors collaborate with hospital care teams as often as daily (depending on the member’s condition and prognosis) to ensure treatment is meeting national criteria for appropriate care. They also support a member’s family and providers in planning for the member’s needs upon discharge.

This integrated, proactive approach yields results. Our analysis shows that members hospitalized for COVID-19 treatment were discharged a day sooner than a national benchmark. Another study found positive results with the youngest members we serve — newborns treated in neonatal intensive care units (NICUs). Our average length of NICU stay was three days shorter than a national benchmark and on par with results published by a leading specialized maternity point solution. That means the members’ employers saw similar savings on NICU cases, without the cost and complexity of adding another partner’s services.

Best-in-class concurrent review for better results

Not all concurrent review approaches are equally effective. Quantum Health clinical leaders point to at least four key elements that contribute to high-performing concurrent review:

  • Collaborative clinical engagement. From the moment a provider submits a request to admit a member, a best-in-class concurrent review team begins anticipating what the next 24 to 72 hours of care might require. They collaborate with the hospital team to understand the treatment plan, then work ahead to authorize upcoming services, preventing delays in care when possible.
  • Seeking appropriate levels of care. It’s typical for a member’s medical needs to evolve during hospitalization. An effective approach engages with the hospital team to spot opportunities to step down care, when appropriate. For example, when post-surgery recovery can happen at a rehabilitation center or skilled nursing facility, cost savings can be significant.
  • Proactive discharge planning. Safe discharge from the hospital is critical to a member’s recovery and to reduce risk of readmission. The best concurrent review teams look for ways to pave the way toward timely discharge. Proactively identifying an in-network home healthcare provider to administer intravenous medications, or a durable medical equipment supplier to source a hospital bed, can prevent discharge delays.
  • Centralized team and systems. In some concurrent review models, staff operate in separate locations and functional silos — benefits specialists here, clinical experts there. They might also lack access to a single, shared system housing members’ medical and benefits information. Quantum Health’s care coordination teams work in the same location, with access to the same member health, benefits and claims data. This helps ensure that engagement and information sharing with members and providers is accurate, efficient and consistent.

Hospital costs are an inevitable expense. When a concurrent review partner proactively engages with members and providers in an effective way, the inevitable becomes more manageable.

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