Hospital Utilization Review Question

  1. I have a question for the group. I currently do initial reviews (someone else does the updates) in an acute care setting.

    I am very curious to learn from others how they have this set up at their facility. Here is our current set-up. It seems overly time-consuming and I cannot imagine this process being followed at larger hospitals...but I could absolutely be wrong.

    We are told we cannot:
    * Attach lab work unless the payer asks for it (this feature has been blocked)
    * Cannot attach an H&P (unless payor asks for it).
    * Cannot attach any progress notes or imaging (unless the payor asks for it).

    We start with the emergency room visit, have to hand-write a summary, labs results, medications, then review the H&P, write another summary on that.

    Any lab work, imaging impressions, medications...we have to type them out by hand. So for ICU and PCU visits, as you can imagine, this can get quite extensive for the first 24 hours.

    Anybody else do it like this?
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    About Jory, ADN, BSN, MSN

    Joined: Mar '12; Posts: 901; Likes: 1,637


  3. by   Been there,done that
    Coming from the payor point of view, I don't want any attachments. I want the clinical information that supports the need for admission. In my case, it is InterQual. Just give me the info that meets InterQual.
  4. by   Neats
    As a insurance reviewer/casemanager I want the supporting labs, physician clinical notes and any imaging that supports the request. If we do not get it we ask for it, you have 48 hours before we close the case for insufficient information. Once we get the information we then review. Even IQ criteria we ask for the documentation. Once we have some sort of History we then reduce the request of information should the request continue.
  5. by   PCORRAL
    How do i get experience with Interqual ?
  6. by   SummerGarden
    Quote from PCORRAL
    How do i get experience with Interqual ?
    A job in the hospital setting within a case management department that uses McKesson's Interqual.
  7. by   gonzoRN
    From my point of view, not interested in separate labs/imaging. If the results are included in H&P, progress notes, then it's redundant to send the extra. However, we don't generally accept your review--it's actual progress notes/H&P. If you have to send review, then we prefer MCG/Interqual review with actual notes cut and pasted in.