End-to-End Revenue Cycle Management

Utilization management is no longer a background function. For health systems navigating rising denial rates, shifting payer mix, and mounting administrative complexity, it has become one of the most consequential drivers of financial performance. Leaders from Universal Health Services (UHS) shared how a more integrated approach to UM is changing outcomes. Their experience illustrates what’s possible when utilization management is aligned directly with revenue cycle performance and executed with discipline.

Pressure is coming from multiple directions

The financial strain facing hospitals reflects broad structural change. Medicare Advantage enrollment has steadily increased and now accounts for more than half of all Medicare beneficiaries. As Luisa Contreiras observed, that shift alone can lower reimbursement per case because Medicare Advantage plans apply more restrictive utilization and payment criteria than traditional Medicare, often in violation of federal rules.

At the same time, denial activity has risen sharply. Among Medicare Advantage payers specifically, 2+ Midnight denial rates have more than doubled since 2020, driven less by clinical variation and more by evolving payer behavior and stricter administrative requirements.

Why the traditional model breaks down

Many revenue cycle operations still follow a step-by-step model. Patient access, case management, coding, and billing operate independently, each focused on completing tasks. This structure limits accountability and obscures outcomes.

UHS moved away from this model. Mark Cannon described the shift as a move from transactions to outcomes; the question is no longer whether each step was completed, but whether the correct financial result was achieved.

Alignment across the care continuum

At UHS, utilization management is coordinated across patient access, case management, and the business office. Each group plays a defined role, but success depends on how well they work together. The process begins with accurate registration and timely admission notification.

Measuring what actually matters

One of the more important changes at UHS involved redefining performance metrics. Traditional indicators such as denial rates or accounts receivable aging provide partial insight but can misrepresent overall performance. UHS adopted a broader measure: Net Inpatient Realization®.

Reducing internal revenue loss

A significant share of lost revenue originates within hospital operations. UHS addressed these issues directly. One critical shift was moving away from self-denial. When care met inpatient criteria, it was billed accordingly.

Holding payers accountable

Even the strongest internal performance cannot fully offset revenue loss. Payer behavior continues to shape outcomes in meaningful ways. It begins with consistent communication. Teams meet regularly with payer representatives to review trends, discuss denials, and walk through specific cases.

Data as the foundation

Data underpins every element of this utilization management strategy. At UHS, analytics drive performance monitoring, trend identification, and informed decision-making. Interactive dashboards offer clear visibility across the revenue cycle, enabling teams to act when issues arise.

A more disciplined approach to performance

The experience at UHS illustrates what integrated utilization management actually looks like in practice. It is alignment across teams, metrics, clinical documentation, and payer strategy; executed consistently and measured against outcomes that matter.