10 One tool to review them all and in the end reimburse them!

<h3>Background</h3> Healthcare systems today face a complicated system of reimbursement with constantly evolving payer criteria. On the Utilization Review side, a lot of resources are spent to keep medical necessity, in patient only and 2-midnight denials minimal. <h3>Objectives</h3> Identify a multi–functional process to optimize and track Peer to Peer conversations and their outcomes. Set up a robust, semi–automated methodology using a web–based database to ensure gaps in process are addressed. Visualize the data in a meaningful manner so payor contracts may be optimized. <h3>Methods</h3> In 2021, Intermountain Health set up a unified peer to peer (P2P) process with one of our biggest payors with Physician Advisor Services (IPAS) doctors reviewing medical necessity denials on one day a week. By 2022, we found there were many payors in the system, with no process for P2P or a way to track the cases and get them reimbursed. Our IPAS team partnered with Care Management and Intermountain Appeals Unit (IAU) teams to develop a robust process to funnel all P2P discussions through IPAS and ensure they got reimbursed. <h3>Results</h3> The impact of this intervention has been the ability to track and ensure that encounters are undergoing a P2P conversation and getting reimbursed what was agreed to. In just over a year and a half of starting this process, our IPAS team has reviewed close to 3000 cases and overturned more than $35 million in denials (figures 1 and 2). This is a huge accomplishment for the system, and helps the patient get the care they deserve without having to burden them with the bill. <h3>Conclusion</h3> Identifying all stakeholders and setting up a process using a semi-automated tool (figures 3 and 4) to transfer cases between various teams ensures opportunity cases are worked and billed accurately.