Appeal RN

[Sue555]

Can someone tell me what it is like to be an Insurance Appeal RN. Is this similar to case management or do you need more experience. Also do you find it better to work on the insurance or hospital side of CM?

[nurseprnRN, BSN, RN]

I've done both, and neither one is a piece of cake, but to be truthful, the deck is stacked in favor of the insurance carrier so you could see that as less stressful. I really hate begging.

On the hospital side: You would have to be proficient with reviewing medical records for evidence that care and need for care met the requirements of the patient's policy per an Interqual or Milliman or other such criterion-based system, getting supporting statements from other areas prn, writing concise reports that show why a denial of payment is inappropriate, and then not going insane when they tell you it doesn't matter, and there is no more appeal, and go fry an egg. You can also get proficient at writing letters to the state insurance commissioner detailing this kind of abuse. Sometimes it works. You walk on air when you go to your car when it does.

On the carrier side: You have to have minute and precise mastery of the review criteria, the policies, and the individual variations for the patient's situations, e.g., policy variations for a particular employer, supplemental policies and their requirements, and internal appeals processes. You will work with an astonishing variety of computer systems to investigate and support your documentation for your decisions. You will sometimes almost weep at making denials when you know it will be detrimental to the patient's wellbeing even though they ought to have known what policies do and do not cover. Sometimes you get them to override the denial and you walk on air when you go to your car.

[d'cm]

My experience with MCO appeals is that it is nothing like CM except that you are looking at medical records from a UR pov. Basically you just summarize the case for the medical director's review and make sure it processed correctly. Proficiency is measured by productivity and compliance. Hospital appeals can be more challenging, some hospitals outsource and nurses are paid per review. A person who can easily put words to paper in an organized way would find this a pretty easy job. Neither one offer much in the way of intrinsic satisfaction, it is just a job.