Transforming Behavioral Health with Effective Utilization Review

If, like me, you’re devoted to effectively and compassionately serving as many behavioral health patients as possible, you understand the importance of financial reimbursement. When a patient is admitted to a facility, clinicians must rapidly assess and document findings and initiate treatment to provide the highest quality care. Meanwhile, behind the scenes, utilization review (UR) nurses scramble to collect the strongest evidence possible from the EMR to secure authorization.

Like it or not, every behavioral health facility relies on utilization review authorization to keep its doors open for patients. This complex utilization review process undermines your objective of successful insurance authorization by requiring UR reviewers to shuffle through chart documents searching for medical necessity criteria, disrupting team collaboration with staff being constantly chased down for documentation, wasting time manually gathering UR supporting evidence, impairing understanding of what is and isn’t working in your current UR process, and lacking quality control to ensure charts are filled out at each step, creating incomplete documentation.

An effective utilization review process supports your facility’s key objective of insurance authorization by prioritizing and scheduling time-sensitive activities, expediting team collaboration, organizing the fact base for execution excellence, and quantifying and classifying criteria scoring.

As the Director of Product Management for ARGO and a former healthcare administrator and clinical leader with decades of experience in Behavioral Health, I understand the objectives and challenges you face. The desire to provide excellent patient care with effective utilization review, ensuring timely and accurate documentation, reducing stress on clinicians and their time away from patients, and minimizing unfunded days are industry-wide goals.

Not every institution succeeds in reaching these goals, but they are achievable. To be successful, you must reduce the burden of the utilization review process on the organization while improving the strength of the evidence to support each insurance phone call without having to hunt down clinicians over missing or incomplete documentation. All the while, you must be cost-efficient and satisfy a long list of regulatory and compliance requirements.

It can be enough to overwhelm even the most experienced behavioral health administrator. Unfortunately, the complex, time-consuming, and often frustrating process is central to guaranteeing quality patient care. If your experience is anything like mine, you’ve been challenged by the discovery of incomplete documentation too close to the UR call, damaging insurance case presentations, lengthy time requirements for the UR nurse to screen multiple clinical documents in a search for key evidence to support authorization, lack of timely communication between clinicians, physically tracking down clinicians to complete documentation, and an absence of metrics that identify processes or personnel requiring additional training or improvement.

ARGO’s Behavioral Health CareChain addresses these challenges and more. Our CareChain solution supports your utilization review process by maximizing insurance reimbursement to improve patient care for those who will benefit from longer stays, improving staff efficiency by speeding up processing so deadlines are met, ensuring time-sensitive tasks like initial authorizations are completed successfully, automatically notifying UR nurses of new admissions, aggregating volumes of patient data for review and presenting relevant information based on diagnosis, accessing and providing summary justification, ensuring readiness for concurrent reviews to reduce insurance provider declinations, lowering UR costs and labor intensity, minimizing uncompensated stay financial loss, and improving clinical practice through KPI metrics.

Behavioral Health CareChain from ARGO gives your organization all the tools necessary to streamline the utilization review process. Automated chart auditing ensures documentation is completed on time, improving the quality of care, reducing the burden on staff, and lowering labor costs. Minimize your unfunded days and help patients receive every day of behavioral healthcare they are clinically entitled to with CareChain, the behavioral health utilization review software created and designed by and for behavioral health nurses and leaders.

ARGO’s CareChain optimizes behavioral health facilities’ utilization review (UR) processes, enhancing insurance reimbursements and patient care. It streamlines documentation, ensures timely authorizations, and improves staff efficiency, minimizing the burden on clinicians and reducing unfunded care. Designed by industry experts, CareChain improves UR outcomes and meets regulatory standards efficiently.