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Let’s be honest! What does Case Management and Utilization Review look like in your Emergency Department?
When a patient comes into the ED, I know the last thing on your mind is documentation strategy. You’re focused on the care of the patient in front of you, getting orders in, managing the family, coordinating with the team. I get it, I’ve been a part of the ED team.
But the reality is that denial rates are at all-time highs. According to HFMA, initial denials are up from 11.41% in 2024 to 11.65% in 2025. Healthcare Finance News reports that in 2025, approximately 2,300 hospitals reported denial-related losses of around $48 billion.
Those aren’t just revenue cycle numbers, that’s real money that was supposed to support real patient care, slipping away because of gaps that often start at admission.
Having worked across level 1 trauma centers, community hospitals, and emergency departments in roles spanning utilization review, discharge planning, complex care transitions, and case management leadership, I can say with confidence that most of these denials are preventable. And it starts with what happens in the first few hours of a patient’s stay.
Here is what we can accomplish when you have engaged Utilization Review (UR) nurses and a team of admitting physicians.
A physician order to admit is just the beginning. What UR nurses need is the clinical picture, the acuity, the comorbidities, the reason this patient cannot be safely managed at a lower level of care. “Admit for chest pain” is a sentence. It’s not a story. Payers want to see why this patient, on this day, needed inpatient or observation-level care. The earlier you paint that picture, the better we can protect the stay.
This is one of the biggest misconceptions I run into. Status designation isn’t something that should be sorted out later by billing. The clinical documentation from the admitting provider directly determines whether a patient qualifies for inpatient status. When clinical findings that support medical necessity are not documented at admission, retrospective clarification efforts can make it harder to support the inpatient level of care. When the documentation does not clearly support the inpatient order, the UR team is left coordinating provider clarifications, resubmitting clinicals, and working against a shortened timeline to obtain a payer determination while the patient is still in-house.
And let’s face it, retrospective work is costing additional dollars. Front-line UR nurses are typically overwhelmed with completing first-day and concurrent reviews, along with sending clinicals. Once that initial denial is issued, you need an experienced appeals team working the denial and assisting with setting up peer-to-peers, if offered. It would absolutely be best practice to prevent the initial denial if possible. Understanding that in this current environment that may not always be possible, it is also important to have a meticulous and highly proficient appeals and denials nurse supporting your team.
Realistically, a patient admitted for pneumonia who also has COPD, Type 2 Diabetes, and heart failure is a completely different clinical picture than a patient with pneumonia alone. It’s a much more complex care plan that may require a longer length of stay. Every active condition being monitored or affecting treatment should be in the chart. For example, malnutrition is a diagnosis that sometimes gets under-documented. Depending on the documented severity, this could be the difference between a CC and an MCC that can directly impact the hospital’s reimbursement. These comorbidities help paint a complete picture of the patient’s clinical complexity and the level of care, monitoring, and resources required throughout the hospitalization. We can advocate much more effectively when the full complexity of your patient is visible.
I see the ED as the front line in identifying patient needs and helping shape the trajectory of care. Understanding that everything moves fast in the ED, it is helpful to the UR team when providers are capturing the full picture of what is occurring with the patient. And let’s not forget the severity of illness while the patient may have been en route in the ambulance! Many times, this is when the patient is at the peak of their medical crisis and is receiving vital treatment. Patient Care Reports from EMTs can also help paint the picture of just how sick the patient is and why hospital care was necessary. Their initial assessment allows for a supported, defensible admission that will, in the long run, save the hospital money.
UR nurses are not here to practice medicine or to create more work for an already stretched clinical team. Consider us your go-to resource when it comes to payer guidelines and an ally that helps with patient benefits and reimbursement. Our goal is to advocate for the patient — including their benefits — and part of that is making sure hospitals are appropriately reimbursed for the care delivered. When billions of dollars in revenue are lost, hospitals struggle to pay for basic needs to keep their doors open. According to the USDA Economic Research Service, between 2005 and 2023, over 140 rural hospitals closed their doors or were converted to non-acute care facilities. Becker’s reports that just this year, in 2026, 18 hospitals completed mergers and acquisitions with larger, more stable health systems. When these smaller rural hospitals close their doors, it’s the patients that suffer. Typically, it is at these hospitals where they can get lifesaving treatment quickly and then, if needed, transfer to higher levels of care.
The relationship between admitting physicians and UR professionals may be one of the most underleveraged partnerships in healthcare. When it works, everybody wins!
Whether you’re a utilization review nurse looking to sharpen your skills, an admitting provider seeking to better understand payer expectations, or a hospital leader focused on reducing denials, we’d love to connect.
We enjoy sharing insights on emerging trends, discussing common challenges, and learning what’s working across organizations.
Contact us today if you have any questions or inquiries!
Cass, A. (2026, June12). 18 hospital M&A’s finalized in 2026. Becker’s Hospital Review.
Morse, S. (2026, April 2). Hospitals’ Net Revenue Leakage Increase 25% Due to Denial Claims. Healthcare Finance News.
Rupasingha, A., & Cho, J. (2025). Federal assistance and rural hospital closings: The impact of the USDA Community Facilities Program (Report No ERR-344). U.S. Department of Agriculture, Economic Research Service.
Williams, J. (2026, January 30). Battle of the Bots intensifies over denials. Healthcare Financial Management Association.
