Utilization Management

Hospital utilization management teams ensure patients get the proper care and services they need in compliance with regulations and payer contracts without overusing resources. At the intersection between clinical decisions, documentation, regulations, payer contracts, billing, and reimbursement, utilization management is an integral component of the healthcare revenue cycle. And thus, has a significant impact on hospital revenue.

An effective utilization management program requires visibility into the entire clinical revenue cycle process to address the vulnerabilities that exist due to the thousands of interdepartmental hand-offs, clinical complexity, regulatory changes, payer contractual requirements, and billing/reimbursement rules. And while most organizations have invested heavily into managing all aspects of their healthcare revenue cycle, few have adequately addressed the needs of utilization management. This is where Versalus Health can help.

The Versalus Health Method to Utilization Management

At Versalus Health, we combine data analytics, clinical, and healthcare expertise to provide hospital utilization management teams with the visibility, tools, and know-how required to improve revenue, eliminate compliance risk, and enhance efficiency.

For years, utilization management has taken a “one-size-fits-all” approach to utilization management, assessing each case with commercial screening criteria and referring cases to a physician advisor for a second review if screening criteria are not met. This process results in complex issues often falling through the cracks and is no longer adequate to meet today’s regulatory intricacies and contractual challenges.

At Versalus Health, we analyze your data and combine it with regulatory, compliance, and managed care expertise to streamline the process and make it more efficient for our clients.

Our team works closely with your utilization management team leveraging internal strength and capabilities while identifying risks and highlighting opportunities for improvement.

Our strategic advisors provide your team with the data and insights to assess utilization management’s impact on the healthcare revenue cycle. The Versalus Health utilization management solution consists of:

Programmatic Approach

The Versalus Health approach combines several interconnected processes and looks at the overarching goals of all of them. The objective is a more effective, efficient utilization management process that supports your organization’s clinical revenue cycle goals. We achieve this through:

Enhancing internal processes

Identifying compliance risks and contractual revenue leakage

Providing solutions to address process vulnerabilities and risks

Managing denials and appeals

Providing ongoing education


We use clear and thorough data to help our clients understand how utilization management impacts the revenue cycle. We monitor processes, regulations changes, and payer performance. Analyzing performance data helps us evaluate:

Accuracy of patient status

Payer responses and denial behavior

Internal methods for managing denials and obtaining payment

Data analysis guides processes and ensures we fix errors while allowing us for fully-informed and compliant decision-making by hospitals.


The Versalus Health solution is tailored to each organization’s needs and capabilities, leveraging a hospital’s utilization management resources and investments.

Utilization Management Outcomes


Regulatory Compliance

Staying current on regulatory issues and compliance is an essential requirement for utilization management teams. The Centers for Medicare and Medicaid Services’ (CMS) requirements and guidance, such as the 2-midnight rule, must guide hospital staff in creating utilization management processes and ensuring appropriate patient statusing.

At Versalus Health, we help our clients to navigate this Rule by providing physician advisor status reviews, monitoring compliance with the Rule, performing compliance audits, and educating attending physicians on the requirements of the Two-Midnight Rule. At a time when hospitals are struggling to hire and retain staff, the Versalus Health approach to the Two-Midnight Rule results in the effective use of staff time.

We constantly monitor the ever-changing regulations to ensure our hospital clients are maintaining compliant processes. By providing our clients with education and training as needed, we help to ensure that our clients have the information they need regarding any regulatory updates.

Revenue Integrity

Improving revenue integrity is the objective. Versalus Health’s program includes :

Patient status review and process redesign (if needed)

Performance trending, audit, and monitoring to address issues and opportunities

Physician monitoring

Education and training for utilization management and other departments

Payer denial review and analysis

Payer contractual requirements for utilization management

Documentation review

Billing cycle review

Identifying opportunities for improvement

Versalus Health offers hospital executives insights into both clinical and financial operations with a Strategic Advisor who can help them act on findings. Combining the clinical and financial data with the Strategic Advisor expertise is unique to the Versalus Health approach and is what guarantees results for our clients.

If your utilization management is looking to go from good to great, you can count on Versalus Health. Contact us today to book a strategy call.

Share This:



Learn how Versalus Health’s innovative appeal solutions can drive increased revenue for your hospital.

Physician Advisors

Physician Advisors

Today’s hospitals and health systems require physician clinical expertise tied to in-depth knowledge of documentation best practices, length of stay management, quality, contracting, billing, and compliance, among other disciplines. Hospitals and health systems have invested significantly in building internal Physician Advisor teams to address these needs.

Regulatory Compliance

Regulatory Compliance

Regulatory compliance is a complex issue for many healthcare facilities, especially as new, updated regulations supersede old ones. Hospitals and health systems may find it challenging to stay up to date with regulatory changes impacting Utilization Management (UM) and the clinical revenue cycle and determine the implications of these regulatory changes on the organization’s processes. Fortunately, Versalus Health can assist your organization with keeping up to date with regulatory changes. We keep our finger on the pulse of regulatory oversight, helping facilities understand the newest regulations, their implications for the Clinical Revenue Cycle , and the latest trends in audits