By Anita Creamer and Liz Madison, Vitals contributors

Who can’t relate to receiving a bill in the mail you thought was already taken care of? Now imagine that bill is because your health insurance decided it was not going to pay for a needed medical service. But did you know that there are teams of doctors and nurses who use their clinical expertise to help stop bills like those from ever appearing?

“We’re helping reduce the emotional impact to patients,” said Dr. Siddharth Raghavan, director of a program within Northern California’s Sutter Health network that tackles the issue. “Otherwise, these patients are recovering, and they receive a letter saying their medical services were not deemed medically necessary. The burden that places on the patient is ultimately relieved by the team of nurses and physicians.”

As Dr. Raghavan alludes, the root of some unexpected medical bills is if services are not deemed medically necessary by insurance. When this happens, an insurance company can then decide to decline paying the bill, leaving the patient to pay for a service that should be covered by their health plan. However, teams at Sutter Health have overturned medical necessity denied claims from 2020 to 2021 where patients would otherwise have owed millions of dollars in unexpected bills. They look to help even more patients in 2022.

Abdoul Ba

Various health systems have teams who work in what’s known as “utilization management.” They evaluate the medical necessity of healthcare services and procedures under the provisions of health insurance plans, using evidence-based guidelines. With the added help of doctors and nurses, the utilization management teams gain greater insight into each case. The medical providers add value to the process by applying industry, regulatory and contractual knowledge, and of course, their clinical expertise.

“These advisors are experts who understand all aspects of the care the patients received,” said Abdoul Ba, who oversees Sutter Health’s Utilization Management team. “Without them, when reviewing a medical necessity denial, you rely solely on the information in the patient records without the ability to go beyond what’s written.”

Ba explained that while some of their work is retrospective—after patients may receive a bill—a lot of their work is proactive.

“Our operations team interfaces with commercial insurance companies on the front end to prevent denials from even occurring. We want to make sure the Sutter patient receives the right care, at the right time, in the right setting,” he said.

While Ba and his team do not provide direct patient care, he acknowledges they can provide some peace of mind. And that has its own healing power.

“We have a team in the Sutter Health network that’s here for the patient, exercising expertise in answering the plans and providing solutions,” he said. “We try and make it as easy for the patient as possible.”

Utilization Management is part of Sutter Population Health Services (SPHS). The SPHS team provides support services that directly and indirectly touch individuals enrolled in value-based payment programs, assisting physicians and hospitals in providing consistent, high-quality care throughout the entire course of an illness or condition at a lower total cost of care.