Case Study: Non-Profit Academic Medical Center achieves $37.9M annualized incremental value and 29:1 ROI with Optum360 commercial physician advisor solutions

Non-Profit Academic Medical Center - Customer Case Study

Non-Profit Academic Medical Center, a 956-bed hospital, needed help with commercial admission reviews beyond the Medicare work Optum360 had been doing. The client asked Optum360 to take on Humana cases (≈150/month), a challenging payer with a high observation rate that threatened revenue and required more defensible medical necessity determinations.

Optum360 deployed its Optum commercial physician advisor solutions—experienced physician advisors who review cases failing first-level criteria using evidence-based medicine. After Optum360 took over Humana reviews, the observation rate fell from 36% to 27%, generating $8.1M in incremental value over 10 months with a 23:1 ROI. The client then expanded Optum360’s reviews to all commercial payers (≈650 cases/month), producing a $37.9M increase in annualized incremental value (from $9.7M to $47.6M) and an improved ROI of 29:1, along with greater revenue and confidence in medical necessity decisions.