Solutions for Medicare and Private Payers

Measurable Results Supporting Hospital Staff and Driving Revenue Integrity

The Problem:
The Blind Spot of the Hospital Revenue Cycle

What is the “Hospital Revenue Cycle Blind Spot?” It is the intersection of clinical decision-making, regulatory compliance, payer interactions, and billing requirements that is typically managed by utilization management (UM). The common approach in healthcare utilization management is to assess every case using commercial screening criteria and refer failed cases to a physician advisor for a second review. This “one-size-fits-all” approach has worked for years, but is it still the appropriate process to address the myriad of complexities and challenges associated with UM today?

The result is a “blind spot” in the hospital revenue cycle that often leads to compliance vulnerabilities and lost revenue. For example, most organizations don’t have clear visibility on the following:

  • Are our short-stay inpatient cases with no CMS exceptions compliant?
  • Do we have patterns of risk on Monday discharges or discharges to skilled nurse facilities?
  • Do we have risk in our TKA or other procedures that have come off the Inpatient-Only list?
  • Which physicians are driving compliance or revenue integrity risk?
  • Are we conducting peer-to-peer appeals on commercial cases that pay the same for observation and inpatient status?
  • Do we have physicians that are statusing Medicare Advantage and Medicare patients differently based on financial class?

Until now, most solutions have focused solely on outsourcing or automating a routine process but have failed to shed light on this “blind spot” and provide the information and guidance required to secure revenue integrity. Versalus Health combines the power of technology and analytics with regulatory, compliance, and managed care expertise to help clients clear the confusion and improve revenue integrity.

Versalus Health’s leaders realized that UM is an integral component of the healthcare revenue cycle and developed a solution that leverages and complements our clients’ in-house talent while providing visibility into processes, risks, and opportunities.

How It Works

Baseline Assessment & Benchmarking

Evaluate compliance risks and healthcare revenue integrity relative to OIG/CMS guidelines or evaluate performance across payers.

Identify  Opportunities

Identify specific sources of compliance risk or revenue opportunities across payers that can be addressed.

Refine  Processes

Revamp operational processes to close gaps and benefit from identified opportunities.

Education & Training

Ensure hospital teams and attending physicians understand new processes and get it right up front.

Ongoing Monitoring & Audit

Continuously monitor performance toward goals and identify other areas of opportunity.


Revenue Integrity

The result? A program that uses your resources efficiently, enhances Medicare compliance, and ensures that you receive the revenue that you are owed.

Do you have your own Physician Advisor team? No Problem

Versalus Health complements your Physician Advisor and Utilization Management teams by providing them with the visibility and targeted expertise they need. Our solution allows them to prioritize the cases that have high impact on compliance and revenue integrity and monitors outcomes to ensure optimal performance.

Don’t have your own Physician Advisor team? No Problem

If you don’t have a Physician Advisor team or your team needs additional support, Versalus Health offers Physician Advisor services on a case review by case review basis or dedicated Physician Advisor Staffing services.

Versalus Health offers a more intelligent approach to managing compliance and revenue integrity for the CMS Two-Midnight Rule. The Versalus Health Medicare solution helps you address questions such as:

  • Are our short-stay+ Inpatient cases appropriate under the Two-Midnight Rule? (+less than 2 midnights)
  • Are some of our long-stay* Observation cases more appropriate for Inpatient under the Two-Midnight Rule? (*greater than 2 midnights)
  • Does the physician documentation concur with my UM process/outcomes?
  • Are we identifying and appropriately billing all Inpatient-Only Procedures?
  • Do we have patterns of delay with Monday discharges, Skilled Nursing Facility discharges, or other population of patients?

How it Works

Baseline Assessment & Benchmarking

Begins by determining the organization’s performance relative to CMS/OIG and industry benchmarks.

Identify Opportunities

Review compliance, revenue integrity risks, and opportunities to create an action plan for improvement.

Refine Process

Prioritize UM staff to focus on the cases with the highest risk and highest opportunities.

Physician Education

Compare physician performance through physician dashboards to enable targeted education on regulations, process, and documentation requirements.

Ongoing Monitoring & Audit

Continuously monitor performance relative to CMS/OIG and industry benchmarks and identify program and case level variance.

Refine action plans.

Versalus complements your own Physician Advisor team or provides physician advisors to perform reviews.



Reduce Compliance Risk

Monitor for outlier patterns, potential gaming, and to ensure high-risk cases are appropriately statused and billed.

Improve Revenue Integrity

Ensure that you are receiving all the revenue that you are owed.

Improve UM Efficiency

Prioritize efforts on the most important revenue integrity and compliance issues.

Versalus’ Private Payer solution relies on payer-specific analytics to prioritize efforts in areas with the largest revenue opportunity. Our solution focuses on addressing the following questions:

  • How are my Medicare Advantage Payers performing relative to Medicare Fee-For-Service?
    • Where am I losing revenue today?
    • What can I do operationally and contractually to improve performance?
    • Where do I prioritize my efforts?
  • How are my Commercial Payers performing relative to each other?
    • Where am I losing revenue today?
    • What can I do operationally and contractually to improve performance?
    • Where do I prioritize my efforts?


How It Works

Baseline Assessment & Benchmarking

Start with the Strategic Payer Assessment to quantify payer performance relative to Medicare and other payers.

Identify Opportunities

Identify payer priority list and greatest opportunities to improve revenue.

Refine Process

Direct UM and appeal efforts to cases identified as most likely to impact revenue.

Physician Education

Compare physician performance thru physician dashboards to enable targeted education on contracts, process, and documentation requirements.

Ongoing Monitoring & Audit

Continuously monitor performance relative to targets, identify new payer tactics and additional opportunities.

Refine action plans.


Improve Revenue

Identify sources of revenue loss and create a plan to stop shortfalls.

Streamline Operational Processes

Develop payer-specific strategies and prioritize efforts to improve contract performance.

Hold Payers Accountable to Contract Terms

Identify and quantify egregious payer behavior so that contract terms can be clarified to improve future revenue.

Interested in learning how your Payers are performing?

Our Strategic Payer Assessment quantifies how payers perform relative to Medicare and each other and identifies opportunities for revenue improvement.

From time to time, Versalus’ clients require assistance understanding the impact of the latest regulatory changes, new private payer behavior, or updates to auditors’ approaches. Versalus Health’s regulatory, managed care, and billing experts review issues and give you the information you need to make sound business decisions.

Some of our most recent projects include:

  • Length of Stay Assessment/Audits
  • Malnutrition Assessment/Audits
  • DRG Integrity Assessment/Audits
  • Behavioral Health Assessment/Audits
  • Inpatient Rehab Assessment/Audits
  • Pediatric Performance Assessment/Audits
  • Contract Renegotiation Support
  • Payer Litigation Support

Interested in any of these projects?

“Unlike my experience with [vendor name excluded], Versalus partners with our UM team to improve our workflow and ensure that we focus on the highest risk and highest opportunity cases. Versalus analytics provide us the visibility we need to continuously improve. It’s no longer about how many cases they or we review. It is about the right review on the right case at the right time that improves our compliance and healthcare revenue integrity outcomes.”

MidWest Hospital

“Traditionally, utilization management (UM) has not been viewed as an integral part of the hospital revenue cycle. I selected Versalus to help me in my dual role as Director of Revenue Cycle and UM. Versalus brought the visibility I needed to manage the complexities between UM, billing, reimbursement, and compliance. They helped me identify high priority issues, fix them quickly, track our progress or any deviations and address them promptly. Our ROI on their program has been impressive and our providers and leaders have been extremely receptive and happy with the partnership.”

Director Revenue Cycle/Utilization Management
Pacific Northwest Health System

Interested in learning how you are doing relative to CMS/OIG and industry guidelines?