Optimizing Utilization Review Workflows to Reduce Hospital Denials

VP of Case Management Recruitment

I talk to hospital CFOs every week, and the conversation always circles back to the same number: denial rate. When a hospital is losing 8 to 12 percent of its earned revenue to denials, the problem is not the payor. The problem is the workflow. Specifically, the problem is what happens — or does not happen — in the first 24 to 48 hours of admission.

Effective Utilization Review starts with front-end accuracy. That means applying evidence-based screening criteria — InterQual or MCG — within 24 hours of admission to ensure the patient is in the correct status. Inpatient versus observation is not a clinical judgment call. It is a criteria-driven determination that, when done correctly, eliminates the vast majority of downstream denial risk.

The second piece is physician advisor engagement. When a attending physician pushes back on an observation designation, your UR team needs a structured pathway to escalate to a Physician Advisor for a peer-to-peer discussion. This is not about overriding the attending. It is about building a defensible clinical case that satisfies both the payor and the CMS Conditions of Participation.

Finally, denial analytics. I see too many Case Management departments tracking denials as a single number. That is useless. You need to break denials down by payor, by physician, by service line, and — most importantly — by type. A technical denial (missing authorization, late submission) requires a completely different fix than a medical necessity denial (insufficient documentation of severity). Until you can see that breakdown, you are treating symptoms, not causes.

When we evaluate UR leaders for our hospital clients, we look for people who can walk into a department, audit the current workflow, identify where the 24-hour screening is breaking down, and redesign the process. That is the leader who turns a 12 percent denial rate into a 4 percent denial rate. That is the leader worth fighting for.

Ben Picozzi

VP of Case Management Recruitment

Ben leads Case Management recruitment with a strategic, relational approach to executive search. He specializes in sourcing passive, high-performing CCM and ACM certified leaders who deliver immediate operational impact.

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