Utilization Management

Utilization Management, Reimagined

The challenge with traditional utilization management (UM) systems is that they are based on legacy technologies with extensions kludged on over the years in response to changing industry requirements. As a result, these system are often clunky, inefficient, and error-prone. Recognizing this pervasive challenge, VirtualHealth made the decision to completely reimagine what a UM platform could be. In this effort, VirtualHealth collaborated closely with UM experts who offered more than a century of combined hands-on experience.

The mission was to streamline, ease, and automate every facet of UM while maintaining the same rigorous standards for operational integrity, timeframe management, and regulatory compliance. The result of this multi-year innovation effort is HELIOSum®, a ground-breaking platform for end-to-end UM, including intake, review, necessity evaluation, determination, and communication. The platform integrates VirtualHealth's award-winning technology, unparalleled automation, and industry-leading configurability.

The Integrated Ecosystem for All Utilization Management Stakeholders

From dedicated portals for providers and their staff to collaborative workflows for intake specialists, UM nurses, and medical directors to integrations with clinical guidelines, claims, and correspondence solutions, the HELIOS® platform provides a unified ecosystem for all UM activities. In turn, this provides health plans with remarkable efficiency, transparency, and auditablity. Every service line determination can be traced back through its history from request and forward through its journey to notification and, where applicable, appeal. Organizations can see who performed what action when, why, and based on what information, aggregating this data for dashboarding and reporting, and drilling down for audit and case review.

The Integrated Ecosystem for All Utilization Management Stakeholders

Manage End-to-End Utilization Review via Centralized Command-and-Control

The HELIOS® platform empowers organizations to manage timely prospective, concurrent, and retrospective utilization reviews while maintaining transparency between UM and care management workflows as individuals transition between care settings. By offering an integrated, seamless, and highly automated ecosystem, VirtualHealth makes it possible to minimize administrative and operating costs while maximizing productivity and eliminating duplicate data entry.

Manage End-to-End Utilization Review via Centralized Command-and-Control

Finally, a Platform That Conforms to Your Organization's Preferences

We believe software should be tailored to users rather than users forced to fit a software's mold. For this reason, all facets of our UM workflows can be configured, from auto-approval engines to work queues to custom guidelines to formularies to notification templates, and all points in between.

In addition, organizations can pick and choose among multiple modules, including general UM, long-term services and supports (LTSS) UM, appeals and grievances (A&G), or all of the above. Modules can be used to meet the full extent of related operational needs or as receivers paired with third party UM systems.

Intake

The HELIOS® platform can receive authorization requests from the broadest range of sources, including providers, facilities, delegated entities, care managers, and third party systems. Each request is uniquely identified, instantly reviewed for auto-approval, and, if pended, promptly assigned to the appropriate UM work queue for further dispositioning.

Intake

Automation

Fully configurable, real-time auto-approval rules minimize manual work and expedite authorization dispositions where appropriate. The rules support the full spectrum of custom criteria that can extend far beyond baseline considerations such as age, gender, and benefits. Individuals win by receiving faster care and health plans win by ensuring resources are limited to those requests that truly require manual review.

Review

Collaborative workflows make it easy for UM intake, nurse, and medical director staff to work together effectively. Seamless integrations with MCG and InterQual ensure teams have access to the most up-to-date clinical guidelines, automated tasking and timeframes keep the team on track, and auto-generated notes and change logs provide transparency on who did what, when, and why.

Automation

Notification

Configurable correspondence templates, dynamic fields, and notification rule engines ensure that determination communications are promptly sent to providers and members. Advanced contact and preference management provide a reliable source of truth for mailing addresses and fax numbers. Integrations with electronic faxing and print fulfillment vendors offer end-to-end automation.

Determination

Health plans must continually balance the requirement for rapid dispositioning against the need to be thoughtful with every determination decision. VirtualHealth delivers technology that supports an optimal equilibrium. Configurable rules, custom questionnaires, and clinical guidelines provide users with everything necessary to ensure a timely, appropriate, and calibrated determination.

Appeals

Comprehensive A&G management capabilities support both determination-based and claim-based appeals. Relevant data auto-populates from the corresponding claim or authorization while intelligent linking allows staff to seamlessly move between the original authorization and the appeal, offering efficiency and minimizing human error.

While Others Focus on Fields, We Watch the Workflows

Far too often, healthcare IT systems are built by identifying the data fields that need to be captured and simply throwing them onto tabs. The result is busy screens, difficult navigation, and general inefficiency in transitioning between tasks, cases, and activities. At VirtualHealth, we focus on workflows, meaning an understanding of how each role actually performs their work. The data fields are arranged intelligently, appearing when and where needed.

The HELIOS® platform is like a well-organized desktop - everything is in its place, intelligently laid out, and within easy reach. While UM generally follows well understood processes, many real-life cases require the ability to move not only forward but also backward, not only in a straight line but also with certain bypasses and sidesteps. One of the most remarkable aspects of the HELIOS® design is that it supports both standard and exceptional workflows with the same level of ease and comfort.

Efficiency Gains Across the Utilization Management Spectrum

Effective UM requires timely cooperation and data exchange among multiple stakeholders on both the payer and the provider side. Given the quantity and frequency of these interactions, even a few percent increase in efficiency can have a profound impact on compliance, costs, and outcomes. Imagine what an increase in efficiency well into the double digits could do for your organization. With VirtualHealth's proven track record in maximizing productivity, we would welcome the opportunity to explore how your health plan can benefit from a switch to HELIOS® for UM.

Efficiency Gains Across the Utilization Management Spectrum

Aligning Processes with Collaboration and Communication

In building a true ecosystem for UM, we thought not only about the payer's need to capture information but also about the clinician's need to provide it; not only the nurse's need to access clinical guidelines, but also the medical director's need to review them; not only about the supervisor's need to manage their workforce but also about the regulator's need to audit their actions. In short, we ensured that all stakeholders could row in the same direction: toward timely decisioning, appropriate utilization, and better outcomes.