Client Results: Streamlining Clinical Medical Necessity Review Process

ProspHire turns a backlog of medical necessity reviews into increased efficiency, reduced costs and improved member satisfaction

Challenge

The client’s authorization backlog continuously surpassed capacity, creating a “bottleneck effect” of compliance risks, overtime expenses and poor member and provider experience. They needed to streamline their clinical medical necessity review process to increase throughout, quality and productivity while reducing administrative cost spend.

Solution

ProspHire partnered with the client to conduct a current state assessment of their medical necessity review process to outline the root cause for low throughput and streamline the process to increase daily case completion volume. The team measured performance by conducting detailed time studies of the process, capturing resource performance against industry KPIs and stakeholder interviews to map out dependencies and identifying gaps and inefficiencies. As a result of the assessment, we developed short- and long-term recommendations to improve throughput and quality over time. The team introduced automation for manual tasks, streamlined communication between managers and clinicians and developed tools to centralize data required to make a case decision, thus making an immediate impact. Long term recommendations included identifying offshore vendor partners to support 24X7 case processing and lower cost admin spend through our efforts. Additionally, the team performed a skills matrix assessment to develop KPIs, SOPs and SLAs to drive higher case volume. This data was also shared with the workforce planning team for forecasting purposes.

Result

As a result, ProspHire helped the client achieve a 33% higher case completion rate with 15% fewer resources. By adopting and implementing our shared best practices, the client saved over $4M in administrative spend over a span of 3 years and increased member satisfaction while doing so.