We have all new staff in our department after our hospital was sold and the long time nurses did not want to continue under new ownership, so, Question regarding UR. We do not use Interqual at my facility and turn in our clinical review's based on "criteria" formualted by our hospital corp. We do not have a format for the UR we send in, we all do it a bit differently but get the info. to right people. I am wondering how other folks do their UR. Same format for all? Wing it? Template? Also, do you seperate your case management and UR nurses or is that job combined? If it is combined what's your average case load like?
Jan 6, '10
I am currently on the receiving end after being hospital based for many years and it seems everybody does it different unless the software formats it. Format per se does not make much difference to payor but the information should be geared for the payors criteria. I have to say however, that the InterQual print out format is the most difficult to decipher. If payor uses Milliman, don't waste a lot of time on IS. SI is everything. Here in NY we are going to an APR payment system which will demand that provider list all comorbities.
Aug 27, '10
I interviwed yesterday for a managed care Concurrent review position and one of the MD's interview questions was--if our contract with a facility is paid based on a DRG, do you want to move that patient ASAP or leave them at facility? I said, move them, but I think the correct answer is leave them where they are. What do you all think? Thank you.
Aug 27, '10
The answer depends on your rationale. DRGs have low and high "trims", so if they move them inside of the low trim there is significant cost savings. However, many common DRGs are only 1 day anyway. Also, you also want to avoid readmissions, so the "appropriate care at the appropriate intensity" line is always safe one to take.
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