ARGO
Optimizing Utilization Review with Automation Technology

Performing a behavioral health (BH) utilization review (UR) for patients involves the manual assessment of narrative charting along with discrete data like vital signs and lab results. Documentation from numerous clinicians is located throughout the electronic medical record (EMR). This complex process can make it challenging for individuals experiencing BH issues to secure insurance reimbursement for their treatment.

ARGO, a recognized and trusted software innovator, developed the BH CareChain (BHCC) solution to automatically scan patient chart documents (both discrete and narrative data) and create accurate and optimal URs. The solution uses automation technology to improve UR economics, optimize workflow efficiency, and reduce labor costs.

BHCC’s electronic workflow, EMR interoperability, HIPAA compliance, intuitive UI/UX screens, and automatically generated key performance indicator (KPI) analytic reports optimize staff workflow while increasing insurance authorizations. BHCC detects training and performance improvement needs, insurance authorization and denial trends, effective documentation practices, and continuous auditing of patient EMRs for evidence of medical necessity. For cases requiring additional insurance evidence, BHCC enables reviewers to immediately notify clinicians to obtain the documentation to demonstrate medical need.

Healthcare providers prefer to focus on patient care rather than paperwork. The highest priority tasks are identified by providing a time-based workflow across the entire patient census, and the UR workload is organized with daily and weekly task planning. BHCC minimizes the time a UR Nurse spends searching the chart for documentation completeness quality and aggregating information to prepare for concurrent review calls. The scheduling feature helps them schedule peer to peers around the provider’s schedules. Succinct (and printable) reports eliminate hunting and searching the chart to be prepared for effective concurrent and peer-to-peer reviews.

“BH CareChain delivers a concise scoring model, summary, and relevant chart documents on a user-friendly screen to help a UR reviewer accurately quantify the strength of every patient case,” says David Engebos, President and Chief Operating Officer of ARGO.

BHCC’s disruptive software innovation streamlines the process of performing URs with insurers, and prevents the need to prepare last-minute reviews, reducing the stress for BH nurses, therapists, physicians, and other healthcare providers. It boosts productivity with automated notifications of new admissions and schedules tasks, reviews, and meetings.

It also tracks the completion of documents to ensure compliance with deadlines. By maximizing insurance reimbursement, a BH patient is more likely to receive needed care, reducing the possibility of a patient being discharged from care when they would benefit from a more extended stay.

“Our KPI analytic reports provide in-depth analysis on insurance approval and denial rates, documentation deadline compliance, and quality indicators,” states Michelle Hook, Director of Healthcare Product Management at ARGO.

While serving in BH hospitals, Hook and her team experienced the frustration of performing time-sensitive activities to demonstrate medical necessity for insurance authorization calls. The traditional UR process encounters increased insurance reviewer scrutiny, a lack of process improvement and accountability metrics, and limited review time, leading to staff burnout and increasing the risk of discharging patients before they receive the full length of stay their clinical symptoms require. ARGO leverages subject matter experts to develop a solution to deliver precise supporting information for securing treatment reimbursements.

BH CareChain delivers a concise scoring model, summary, and relevant chart documents on a user-friendly screen to help a UR reviewer accurately quantify the strength of every patient case

From initial authorization to the final appeal, ARGO’s cloud-based software automates critical workflow processes through four simple steps: prioritizing and scheduling time-sensitive activities, quantifying UR documentation strength, expediting team collaboration, and organizing a fact base for execution excellence.

ARGO’s BHCC streamlines the complex UR workflow process. The standard workflow currently used to prepare for concurrent reviews, for example, involves manually searching through numerous electronic chart assessments and progress notes, and visually through voluminous documentation. The software automatically scans relevant chart documents and summarizes the symptoms to display corresponding documentation sources.

ARGO is currently marketing and demoing its BHCC product. It will serve many healthcare organizations in the U.S. by helping them adopt its solution to evaluate their ROI and performance with respect to treating patients with BH issues.