Picture this: a participant is hospitalized, and you don’t hear about it for a day. The claim comes back coded inpatient. No one checked whether that was medically necessary. Your utilization management policy says everything’s under control. But the bill says otherwise. In PACE, that gap carries a real cost.
This scenario isn’t a hypothetical. It’s what three PACE programs experienced before shifting to the proactive UM model offered through IntusCare’s PRISM suite of solutions.
In our recent webinar, Stop playing defense: Three PACE programs on proactively managing utilization, IntusCare Chief Population Health Officer Laura Ferrara sat down with leaders from One Senior Care, Element Care, and Mountain Empire PACE to unpack exactly how they made that shift.
But before diving into the signs that a program is playing defense on UM, it helps to be clear on what utilization management actually means in a PACE setting.
What is utilization management in PACE?
In PACE, utilization management isn’t about denying care to save money. It’s about determining what level of care each participant actually needs medically, not administratively. It’s about having a review process for decisions, and making sure your policy is built into daily workflows.
This distinction matters because, left unmanaged, the default decision-maker isn’t your clinical team. And the result is whatever care (and billing code) a hospital defaults to first.
The three programs on our panel each recognized these patterns before they changed course. Here are the signs that tipped them off.
Sign #1: You don’t find out when your participants are hospitalized
Mountain Empire PACE, a small, rural PACE program in southwest Virginia had essentially no utilization management prior to working with IntusCare, according to PACE Director Ruby Kennedy.
“We are a very small player in an area where there is one health system, and we were sort of at their mercy,” Kennedy said. “If they wanted to go inpatient, that’s what we were subjected to. We got the bill, and we paid it… we felt very powerless.”
Part of that sense of powerlessness came from something more basic than billing disputes: the program often didn’t know when a participant had been hospitalized. “There were times we wouldn’t find out until a day in,” Kennedy said.
Compare that to what she describes as the first real sign that their shift in UM strategy was paying off:
“For the first time ever, these hospitals were actually notifying us when they had one of our [participants]… Suddenly we feel actually like a relevant player in healthcare in this area.”
Knowing the moment a participant is admitted isn’t a nice-to-have. That visibility is the foundation everything else in utilization management is built on. You can’t manage a level-of-care decision, coordinate a discharge, or catch an unnecessary admission if you don’t know it’s happening.
Sign #2: Every admission defaults to inpatient (or a helicopter). And it’s costing you.
At One Senior Care, the gap wasn’t visibility. It was structure. Before engaging IntusCare, Chief Nursing Officer Betty Mikovich said the program approached UM reactively, with little pushback on hospital decisions. “Whatever the hospital required of us, we said, ‘Okay,'” she said.
One of the more striking discoveries once they started reviewing the data was how often participants were being air-transported between facilities, sometimes for trauma-level billing that didn’t match the situation.
“It seemed like the smaller hospitals, all they want to do is air transport… to another hospital,” Mikovich said. “Some of the hospitals… it was a 10-minute air ride to get them to the location.”
Those requests had been automatically approved, with no review of whether they were appropriate. After building a formal escalation and review process, that changed. “We have rarely, since implementing with IntusCare, paid for an air transport,” Mikovich said.
The same pattern shows up in the more everyday decision between observation and inpatient status.
Hospitals will often default to requesting an inpatient level of care. As Ferrara put it, “It’s not uncommon for hospitals to ask for an inpatient level of care for every admission because they’ve always done that.”
But once a program consistently applies the same clinical criteria to every request, that starts to shift. Once proactive review is in place, Ferrara says, “We see on average about 27% of authorization requests end up being observation.”
For Element Care, that consistency translated directly into savings.
“We started seeing savings month over month over month, and significant,” said Chief Medical Officer Dr. Anthony Zizza. “It’s a little over $100,000 a month. And that’s growing.”
Importantly, he added, that savings isn’t coming from denying care: “It was coming through appropriate classification of billing and good cooperation with Intus and with the hospital.”
Curious how your program’s numbers stack up?
Our PACE Financial Benchmarks Report is a good place to start. Or reach out to our team to see where your program is leaving money on the table.
The fix isn’t complicated in concept, even if it takes work to build: a review process that checks high-cost and default-to-inpatient requests against clinical criteria before they’re automatically approved.
Sign #3: Your policies exist on paper, but not in practice
The hardest part of this shift, according to nearly every panelist, wasn’t writing a UM policy. It was operationalizing it.
Before working with IntusCare, One Senior Care had, in Mikovich’s words, “very, very weak policies and procedures around utilization management.”
And even after new policies were drafted, putting them into daily practice was its own project. “There’s one thing creating a workflow. There’s the other step, is really operationalizing it,” she said. “One of the things we underestimated was the degree of the changing in the workflow.”
One of the biggest underestimated hurdles: getting physicians comfortable pushing back on hospital UM teams in peer-to-peer review. Dr. Zizza described the hesitation his providers initially felt: “Well, I’m going against somebody who’s doing this for a living. I can’t do that. I’ll approve everything.”
But that changed once physicians had specific, guideline-backed information for each case.
“Once they have the guidelines, and they get those guidelines specifically to that patient… they really felt empowered,” Zizza said. “UM is not something done to them, it’s something that they partner with.”
A policy that exists only in a document doesn’t change any of that. It’s the training, the workflow integration, and the provider buy-in that turn a policy into an actual practice.
How to shift from reactive to proactive utilization management
If any of these warning signs sound familiar, the good news is that none of these three programs started with a perfect system. They built visibility, implemented a review process, and integrated policy into workflows one at a time.
Mikovich’s advice to newer programs: don’t wait for a specific census threshold to get going. “My opinion is day one,” she said. “Have that part of your integration process from the very get-go.”
Ready to start shifting your UM approach?
None of this requires a full overhaul to start. Here’s where to begin.
First, hear directly from leaders at One Senior Care, Element Care, and Mountain Empire PACE on how they made this shift in our webinar, Stop playing defense: Three PACE programs on managing utilization before it manages you.
Next, explore three ways PACE programs can start proactively managing utilization. And see how your program’s utilization and costs compare to benchmarks with our PACE Financial Benchmarks Report.
And when you’re ready to talk about what a proactive UM approach could look like for your program, book a call with our team.
