Background

A rapidly growing PACE (Program of All-Inclusive Care for the Elderly) program sought to improve its utilization management processes, looking for innovative solutions to enhance operational efficiency and cost-effectiveness. The organization currently serves nearly 800 participants.

Challenge

The PACE program needed to streamline care coordination, service authorizations, and claims review processes. The goal was to ensure high-quality, medically necessary care while reducing unnecessary expenses. Given the complex and costly nature of PACE program participants, this can be particularly challenging.

Solution

Intus Care introduced its Utilization Management as a Service offering, which combines advanced population health technology with in-house clinical expertise to optimize care system and health plan UM processes. The comprehensive solution includes:

• Population Health Management: Utilizing the Intus Care platform and risk stratification models, as well as effective population health management strategies, to identify and analyze high-risk population segments.
• Retrospective Review: Assessing completed cases to validate service necessity, correct documentation, and manage provider appeals.
• Delegated Utilization Management: Implementing proactive measures such as prior authorization, concurrent review, hospital and contracted provider management, and transitions of care processes.

Results and outcomes

Cost savings

Over $450,000 in direct savings over 4 months, from authorizing observational rather than inpatient admissions. $222,000 from proactive utilization management.

Clinical outcomes

Inpatient admission rate decreased by 25% (January to August 2024).

30-day readmission rate dropped by 40% (January to August 2024).

Proactive management

Net billed for short-term inpatient stays in April 2024, with claims pending payment, amounted to $33,668: Targeted reduction of $24,668.

These results demonstrate the effectiveness of Intus Care’s offering in optimizing utilization management for complex senior care programs, presenting a compelling value proposition for the broader value-based care market.

Ready to learn more about our Population Health and Utilization Management services? Book a demo today.