Workflows/Utilization Review — Cardiac Rehab Program
15 decisions · 15 governed
2
AP

Utilization Review — Cardiac Rehabilitation Program

In ProgressStep 3 of 5
Started 8 Aug 2026, 08:00 · Quarterly review cycle · Triggered by automated schedule + utilization threshold alert
AP
Dr. Aisha Patel, Medical Director
Process Timeline
Program Data Collection
08 Aug, 08:00 – 08:07 (6m 44s)
Collected utilization data for cardiac rehab program: 312 active members, 4,218 sessions YTD, extension requests, completion rates, readmission outcomes, and cost data.
2,847 claims records, 312 member profiles, 14 peer plan benchmarks
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Benchmark Analysis
08 Aug, 08:07 – 08:19 (11m 52s)
Compared program metrics against HEDIS cardiac rehab measures and 14 regional peer plans. Calculated variance across 6 key metrics.
14 peer plan datasets, HEDIS benchmark tables
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Utilization 18% above peer median. Extension rate 67% above benchmark. Per-member cost 30% above benchmark. However, 30-day readmission rate 31% below benchmark.
Variance Driver Analysis
08 Aug, 08:19 – ongoing
Analyzing clinical, operational, and financial factors driving variance from benchmarks. Identifying root causes and distinguishing clinically justified variance from operational inefficiency.
3 of 4 variance drivers analyzed
Medical director review required
Recommendation Development
Generate specific, evidence-based recommendations for program optimization — balancing cost efficiency with clinical outcomes.
Medical director approval required before stakeholder distribution
Board Risk Committee Briefing
Compile quarterly utilization review report for board risk committee with executive summary, data visualizations, and approved recommendations.
Medical director sign-off required

Step 3: Variance Driver Analysis

In Progress
What the agent is doing
Performing root cause analysis for each metric where your plan significantly deviates from benchmarks. Distinguishing between clinically justified variance (which should be maintained) and addressable inefficiency (which should be targeted for improvement).
Variance Drivers Analyzed
High Extension Rate (14.2% vs 8.5%)
Root cause: Higher comorbidity burden (avg 2.8 vs 2.1 benchmark). 78% of extensions involve diabetes or obesity co-diagnosis.
Clinically justified
Recommendation signal: Implement comorbidity-adjusted extension criteria rather than reducing extensions.
Strong Enrollment (68% vs 55%)
Root cause: Automatic referral pathway from discharge captures more eligible members than opt-in models.
Positive variance — maintain
Correlated with 31% lower readmission rate.
Elevated Cost ($6,730 vs $5,200)
Root cause: Valley Heart Associates (47% of volume) bills $187/session vs $152 regional average.
Addressable — contract renegotiation
Projected savings: $340K/year if aligned to regional average.
Phase III Completion Rate (41% vs 45%)
Status: Analysis in progress — reviewing member dropout patterns and barriers to completion.
Pending
Governance Checkpoint
Medical Director Review Required
Variance analysis must be reviewed by medical director to validate clinical justification classifications before recommendations are generated. Particular attention needed on extension rate classification — this drives the largest cost variance.
Evidence for This Step
Claims data — 4,218 cardiac rehab sessions YTD
HEDIS 2026 benchmark tables — CR-1 through CR-4
14 peer plan utilization datasets (anonymized)
Valley Heart Associates contract — current rate schedule
ACC/AHA 2026 cardiac rehab guidelines — extension criteria
Member comorbidity profiles — 312 active program members
Four Pillars
Meaning: Utilization variance → deviation from benchmark expressed as percentage. Clinically justified → variance attributable to patient population characteristics supported by clinical evidence.
Process: Step 3 of 5 per utilization review workflow UR-WF-002
Evidence: 3,173 records analyzed, 14 peer datasets, 2 clinical guideline sources
Record: EB-2026-0808-HP-02348-S3 · 08:19:15Z