Data-Driven Solutions Built to Optimize Utilization Management in the Healthcare Revenue Cycle

Advanced analytics meets unparalleled industry expertise to optimize the role of utilization management in healthcare

The Problem:
The Blind Spot of the Healthcare Revenue Cycle

While most organizations have invested heavily into managing all aspects of their healthcare revenue cycle, very few have adequately addressed the “blind spot” that exist in the revenue cycle. This blind spot refers to the convergence of clinical decisions, evolving regulations, inconsistent contractual obligations, billing rules, and reimbursement management. The performance of the hospital’s utilization management (UM) department plays an integral role in managing these challenges.

UM has not been equipped with advanced tools to improve visibility and impact on the revenue cycle. Hospitals have not invested to maximize efficiency. They have spent in Case Management and Internal Physician Advisors but not provided them with the right tools to ensure optimal performance.

Our Solutions

Analytics to Identify Opportunities

Versalus Health has developed a portfolio of advanced analytics designed to “close the loop” between UM, billing, reimbursement, managed care and compliance. Versalus’ analytics utilize hospital encounter, billing, reimbursement and utilization management data and compare it against national benchmarks, hospital, payer-specific contract terms, and billing rules in order to detect compliance risk, identify revenue integrity opportunities, discover processes or technology flaws, pinpoint areas for additional education and tailor process improvement based on findings.

Services to Improve Performance

Versalus Health supports hospitals and health systems with specialized expertise including Physician Advisors; regulatory experts; case management, clinical documentation, coding, finance, billing, and revenue cycle professionals. Our services are tailored to each client and are designed to leverage internal capabilities, resources, and talents. Versalus helps clients identify issues and opportunities quickly, take the actions needed to improve performance, and continuously monitor to ensure sustained results.

How We Help Clients:

Utilization Management, Billing, and Regulatory Compliance Process Redesign

Physician Advisory Services

Including Concurrent and Retrospective Case Reviews

Medical Director Audit Reviews and Support

Physician and Utilization Management Education

Medicare and Private Payer Appeals

Private Payer Contracting and Negotiation Support

Hospital Payment Litigation Support

CMS, OIG, DOJ support

The Versalus solution leverages a data-driven, outcomes-focused approach to optimize our client’s case management and physician advisor teams. For organizations that have established a Physician Advisor team, we offer solutions that complement their teams. We provide them with the information they need to effectively do their job. However, for those that have not developed internal capabilities, we offer a program that includes all physician case reviews, audits, appeals or specific expertise to complement existing programs.

The result is a process that provides unprecedented visibility, ensures efficient use of resources and in-house capabilities, increases revenue, improves compliance, and maximizes returns on managed care investments.

Our Results


  • Align Medicare compliance metrics with national benchmarks
  • Ensure that your process is delivering compliant outcomes

Revenue Integrity

  • Receive all the appropriate revenue that you are owed for Medicare and Private Payers populations by quantifying and understanding sources of revenue loss


  • Reduce manual screening reviews by up to 80%
  • Focus valuable Case Management and Physician Advisor resources on the most important activities
  • Most Organizations feel that their processes are compliant, yet they don’t have visibility on whether their outcomes are compliant.

Do you know whether your processes are producing the compliant outcome that you expect?

  • Most organizations have no visibility on whether they are leaving revenue on the table or why.

Are you getting all the revenue that you are owed?

  • Most organizations apply commercial screening criteria to a 100% of cases and perform physician reviews on cases that do not meet the criteria. This approach wastes valuable time on most of the cases but doesn’t apply enough attention on some of the cases.

Do you know what cases fall into each category?

I implemented Versalus at my last organization with tremendous success. When I accepted the position as CFO for a 6-hospital system, one of my first calls was to Versalus. We are now implementing the Versalus solution for both traditional and managed Medicare. I’ve been a finance executive for 25 years and can really appreciate the true partnership that we’ve had with Versalus. We worked together to craft solutions that leveraged our internal expertise with their analytics. The results have been very tangible: improved revenue, enhanced compliance, and much better performance visibility.”

System CFO
Six-hospital system

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Versalus Health Blog

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By Joseph R. Zebrowitz, MD Over the last few years, there has been a trend toward automating the medical necessity UR screening process using software to extract clinical data and either apply commercial criteria or create an acuity score.  As I have strolled across trade show floors, I see company after company touting what appears… Continue reading

Vulnerabilities Remain Under Medicare’s 2-Midnight Policy Copy

In 2016, the Office of the Inspector General (OIG) published a report, “Vulnerabilities Remain Under Medicare’s 2-Midnight Policy”, summarizing the first findings of hospital billing patterns since the implementation of the Two-Midnight Rule. The results surprised many who believed that a slight adjustment to existing protocols would accommodate the Rule changes. Despite the findings, many hospitals have not addressed the guidance.

You Can’t Get the Right Answer if You Don’t Ask the Right Question

In 2013, the Centers for Medicare and Medicaid Services (CMS) finalized the “Two-Midnight” Rule addressing when beneficiary hospitalizations are appropriate for inpatient payment under Medicare Part A. CMS adopted the “Two-Midnight” Rule to simplify the beneficiary admission decision establishing a new standard for selecting whether a beneficiary should be considered inpatient or outpatient. CMS stated… Continue reading

Assess Your Risk and Opportunities

Do You Know How Your Program is Performing Relative to Established Benchmarks for Compliance and Revenue Integrity?

Our team can perform a Compliance Baseline Assessment to evaluate how your program is running.

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