CLIP Opportunity Lite / Public hospital data
See your hospital’s revenue opportunity
Start with your hospital’s publicly reported data to explore where inpatient revenue protection and physician-advisor capacity may be worth a closer look.
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How we use CLIP to address the opportunity
The calculator estimates revenue that may be at risk when inpatient-appropriate Medicare cases remain in observation. CLIP addresses the utilization-review workflow behind that exposure.
CLIP is an internally validated clinical-financial decision engine for medical-necessity and patient-status decisions, built around physician-advisor judgment, payer rules, escalation logic, institutional configuration, with measureable downstream outcomes.
1
Organize the clinical story
CLIP assembles the patient's clinical trajectory, severity, treatment intensity, monitoring needs, risk, and expected length of stay into a structured case review. This reduces the time UM teams and physician advisors spend reconstructing the case before they can evaluate status.
2
Surface what is missing
CLIP identifies documentation gaps, inconsistencies, and weak links that could delay or undermine an inpatient-status determination—without inventing clinical facts. UM teams can address those gaps while the patient is still in the hospital.
3
Prepare defensible status reasoning
CLIP connects the clinical record to the applicable payer rules and prepares a structured inpatient-versus-observation rationale for human review. It also supports escalation and peer-to-peer preparation when physician-advisor judgment is required.
Capacity and revenue connection
By moving case organization, gap detection, and first-pass reasoning upstream, CLIP expands the capacity of both UM teams and physician advisors. UM nurses can prepare more decision-ready reviews, while physician advisors focus their limited time on cases requiring clinical judgment—helping hospitals address inpatient-appropriate cases before discharge, retrospective correction, denial, or lost reimbursement.
The calculator estimates the potential exposure. CLIP helps UM teams and physician advisors address the patient-level decisions and workflow conditions that may be producing it.
Modeled exposure is an estimate based on public data. It is not proven loss, guaranteed recovery, or realized savings. Human reviewers retain final decision-making authority.
About the calculator
See where inpatient vs. observation decisions may be creating financial exposure.
Inpatient versus observation decisions can have a meaningful financial impact — particularly when complex cases are reviewed too late, physician-advisor capacity is limited, or the clinical picture does not align cleanly with payer requirements.
The CLIP Opportunity Calculator uses publicly available hospital data to estimate the potential financial exposure associated with inpatient and observation status decisions at your hospital.
Enter a hospital to generate a hospital-specific screening estimate based on Medicare fee-for-service inpatient and observation utilization, reimbursement benchmarks, and publicly available hospital data.
What the calculator is designed to answer
The calculator is not intended to tell you that a hospital is losing a specific amount of money.
It is designed to answer a more useful first question:
Is there enough financial and operational signal here to justify a closer look?
The results provide a starting point for evaluating whether inpatient vs. observation decision-making, physician-advisor capacity, escalation processes, documentation, or other utilization-management workflows may warrant further review.
What the calculator shows
Potential reimbursement exposure
An estimate of the reimbursement associated with cases that may warrant closer examination of inpatient versus observation status.
This represents the broader financial signal identified in the available data. It does not mean that every modeled case should have been inpatient or that the full amount reflects actual financial impact.
Estimated opportunity to investigate
A more conservative portion of the modeled exposure intended to help hospitals identify whether further analysis may be worthwhile.
Determining whether a true opportunity exists requires comparison with the hospital’s actual case mix, status determinations, payer requirements, denials, documentation, escalation patterns, and physician-advisor activity.
Potential physician-advisor capacity impact
The calculator also estimates how many additional Medicare fee-for-service inpatient cases could receive physician-advisor review if review capacity were expanded.
This is a capacity estimate — not an estimate of total hospital discharges or the number of cases that necessarily require a status change.
Its purpose is to help illustrate the potential operational impact of extending limited physician-advisor and utilization-management resources to more of the cases where additional clinical review may matter.
An important limitation of the estimate
The calculator currently models Medicare fee-for-service data only.
Medicare FFS has represented roughly one-quarter of all-payer inpatient discharges nationally in recent years, although the percentage varies substantially by hospital and may be considerably higher in some rural and critical access hospitals.
That means the calculator is examining only one portion of a hospital’s payer population.
It does not estimate the total potential impact across Medicare Advantage, commercial insurance, Medicaid, or other payers. Depending on a hospital’s payer mix, reimbursement rates, utilization patterns, and status-management processes, the actual all-payer financial impact may be larger — or materially different — from the Medicare FFS signal shown here.
The calculator should therefore be viewed as a screening tool, not a savings guarantee or financial forecast.
What happens when the calculator identifies a signal?
A meaningful result does not automatically tell us why the signal exists.
The underlying issue could involve:
- status decisions occurring too late in the hospitalization;
- limited physician-advisor availability;
- cases not being escalated for secondary review;
- clinical documentation that does not clearly support the appropriate status;
- payer-specific requirements;
- workflow or communication gaps between utilization management and physicians;
- missed peer-to-peer or escalation opportunities; or
- no material problem at all once the hospital’s actual data are reviewed.
That is why the next step is validation.
A consultation with ClinEfficiency Pro can help determine whether the signal identified by the calculator is reflected in the hospital’s actual workflow and financial performance — and, if so, where the opportunity exists.
Where CLIP fits
CLIP — Clinical Intelligence is designed for the cases where inpatient versus observation status is not obvious and timely clinical judgment matters.
CLIP supports utilization-management and physician-advisor teams by bringing together clinical information, payer rules, institutional configuration, escalation logic, and physician-advisor judgment to support more timely and defensible medical-necessity and patient-status decisions.
The goal is not simply to change more patients to inpatient status.
The goal is to help ensure that the right cases receive the right level of review at the right time — protecting appropriate reimbursement while supporting defensible, clinically grounded status determinations.
The calculator identifies the signal. ClinEfficiency Pro helps determine what is driving it. CLIP helps your team act on it.
Already have results? See what they mean →
Recent policy changes may affect revenue
PAULA currently tracks 165 payer-argument denial scenarios, including 26 Physician Advisor / status-integrity scenarios tied to inpatient-only and Two-Midnight policy risk. Not all scenarios apply to any one hospital.
View current policy intelligence →