O4 Hubs detail
O4 Detail Hero Banner

Testimonial: Overturning concurrent denials

See how one client strengthened its utilization review.


O4 1 Column (Full)
O4 Video Player Component

[Video Title] A partner to trust: Beyond just physician advisor services

Hi, my name is Elizabeth Reffitt. I’m the manager of case management services at St. Claire Regional Medical Center in Moorhead, Kentucky.

[Title Screen] Correct reimbursement with Optum360

We have benefitted from their wonderful level of expertise and professionalism. At our facility, we believe patients are the center of everything we do. And we want to be paid the right amount for the care patients require in our hospital. We don’t want more, we don’t want less. We just want what’s right.

 [Title Screen] An unmatched foundation for medical necessity

They have the expertise, the huge library, the information, the data that’s needed to back up their decision. Their, just excellent knowledge and skills has been invaluable to us to help prevent denials for hospitalizations.

[Title Screen] Overturning concurrent denials with Optum360

A patient may have been in the hospital just two or three days, and we can see very clearly that they’re still requiring a lot of services that they can only receive as an inpatient in the hospital, yet their payer is already telling us that from this day they’re going to deny any further care. So, they set up any peer-to-peer discussions in a very timely manner, and frequently are very helpful with getting those denials overturned.

[Title Screen] Defensible medical necessity recommendations

We’ve had a short stay review by our QIO. I was able to, of course review this chart, pull that letter right out, and on the phone call, I had highlighted the portions of the letter where the physician had stated what the concerns were and why this patient required an inpatient stay, and use that along with just a couple of other things and then that stay was approved. So, it was very helpful.

[Title Screen] Complementary value-added services

The first thing that comes to mind is the education opportunities that they provide us. They don’t just provide this to the case management staff. They also have education for our physicians. When we first started with the program, we had physicians and others come and do face-to-face education.

[Title Screen] Working with Optum360

They’re thoughtful, they’re considerate, they’re timely. If we have any questions of concerns, we have a team that we work with. When we send a referral to them their response is very timely, it’s very professional, the letters we get, the calls that we get. If there’s additional information needed they’re very helpful.

O4 1 Column (Full)
O4 Text Component

Elizabeth Riffett, manager of case management at St. Claire Regional Medical Center, explains the value her organization gains from partnering with Optum Physician Advisor Solutions on utilization review.

Contact an expert to learn more.