CHA Hollywood Presbyterian Medical Center

The Challenge

Hollywood Presbyterian Medical Center was experiencing significant overutilization of Observation level of care due to inconsistent daily clinical review processes and limited oversight of medical necessity. Key challenges included:

• Lack of daily clinical criteria and medical necessity validation
• Limited transmission of clinical documentation to payors, resulting in communication delays and limited follow-up
• No standardized process to reconcile physician orders with payor authorizations to ensure each observation day was medically necessary and appropriately authorized
• Inconsistent alignment between physician documentation, services provided, and the level of care billed

Our Approach

bServed implemented a structured utilization management workflow focused on clinical accuracy, payor alignment, and regulatory compliance by:

• Performing daily medical necessity reviews using evidence-based clinical criteria
• Establishing proactive communication with payors to ensure timely clinical updates and authorization management
• Reconciling physician documentation, physician orders, payor authorizations, and actual services delivered on a daily basis
• Ensuring the approved level of care was accurately reflected in the hospital information system to support compliant billing and reimbursement

Results

The implementation created a standardized, clinically driven observation management process that improved documentation accuracy, strengthened payor alignment, and enhanced billing compliance.

• Standardized, clinically driven observation management process
• Improved documentation accuracy and payor alignment
• Enhanced billing compliance and reimbursement integrity
• Reduced administrative burden associated with denial management

The result was a more compliant utilization management program, improved reimbursement integrity, and reduced administrative burden associated with denial management.