INDICIATM
FOR UTILIZATION REVIEW
Build your business case
Created by Milliman Care
Guidelines
For hospital decision-making
teams
How to Use This Resource
• If your organization is considering Indicia for
Utilization Review, you may have other team
members who are less familiar with the product
• We have designed this PowerPoint deck so that you
may customize it or use any of its assets in
presentations to your team
A Word About Content Rights
• We’ve left these slides editable so they can be
easily used
• Once you have adapted the deck, however, we can
no longer be responsible for the validity or accuracy
of its content
• The names Milliman Care Guidelines and Indicia are
trademarks of Milliman Care Guidelines and
screenshots of our products are the property of
Milliman Care Guidelines
Indicia for Utilization Review
• Designed for providers
• Contains the most thoroughly researched, most
broadly used care guidelines in the industry
• iPad enabled
• Supports utilization review efforts
• Helps avoid inappropriate admissions
Tackles Practical Needs
Admissions
Utilization Review
• Easy to look up and interpret
criteria
• PDF, save and print
capabilities
• Streamlined user experience
for any member of the care
team – triage nurse or ED
physician alike
• Automated
admission/discharge
indications across various
care settings
• Visual go/no-go indication
• Can integrate with existing
case management or EMR
software
• Mobile access for iPad
• Internet-like search
capabilities
How Indicia would benefit us
• Helps ensure focus on patients’ path to health
• Supports existing workflow
• Helps achieve reimbursement and care
management goals
• Facilitates conversations with payors about
appropriate care
Our Organization’s UR Challenges
• [What challenges are you experiencing with
regard to your existing UR process? Place those
here.]
Our Plans for Indicia Include
• [If you have specific goals or business needs
that could be addressed by using Indicia for
Utilization Review, include those here.]
How It’s Being Used
ED
Admissions
Ambulatory
and
Procedural
Admissions
Care
Transition
and
Readmission
Weekend
Admissions
Critical
Access
Hospital
Utilization
Example Use Case
Weekend
Admissions
What Happens in Our Organization at
Night or on a Weekend?
• Who is responsible for making judgment calls about
admission?
• Are admissions handled consistently and in accordance
with the most up to date, valid criteria used by our payors
and CMS?
• Is the patient receiving the appropriate level of care?
• How is that decision documented?
• How is the case manager brought up to speed Monday
morning?
• How can we ensure we will be reimbursed for this care?
What Are the Costs Over the Course of
One Weekend?
[EXAMPLE]
Time getting
Monday morning
staff up to speed
30
minutes
per patient
Resources
looking up
documentation
after the fact
30
minutes
per patient
Lost
reimbursement
revenue due to
inappropriate
admission
$12,000
X5
patients
=
2.5 hours
X5
=
patients
2.5 hours
X 5 bed
days
=
$60,000
What Are the Costs Over the Course of
One Weekend?
[Fill in your own estimates here]
Time getting
Monday morning
staff up to speed
[How many
hours/minutes
do you spend
per patient?]
Resources
looking up
documentation
after the fact
[How many
hours/minutes
do you spend
per patient?]
Lost
reimbursement
revenue due to
inappropriate
admission
[Average
cost per bed
day]
X#
patients
=
X#
=
patients
X # bed
days
=
X hours
X hours
$X
Selection Criteria: How Indicia Stacks Up
Ease of use
Clarity of indications
• Guidelines lookup and
search by any staff
member
• Visual indications for
admission
Effective use of time
• PDF, save or print the
guideline for case
manager review on
Monday
Let’s Walk Through a Typical Admission
• A patient presents to the Emergency Department
in some respiratory distress
• Given the patient's condition the admitting
physician thinks she should admit him
• The triage nurse is responsible for determining
the appropriateness of the admission according
to the evidence
Easy
Guideline
Lookup
The Triage Nurse looks up the criteria for hospital admission for a patient with
acute exacerbation of Asthma on her iPad.
Clear Indication
for Admission
The Triage Nurse documents the symptoms and a yellow bar indicates the
patient does not need to be admitted.
Quick
Documentation
The Triage Nurse then views indications for Observation Care, determines he’s a
good fit, and documents her decision for the Case Manager by saving a copy of
the indications to her department’s shared drive.
How will Indicia Benefit Our
Organization?
• Promoting evidence-based clinical decisions
• Improving documentation for utilization review
• Improving reimbursement rates by using the
same, evidence based best practices used by
our health plans
• Reducing staff time by x% and saving up to $x in
inappropriate admission costs [insert your own
figures here]