CM VS UR

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We are looking at remodeling our CM program for inpt hosptial. Any suggestions on leading practice?? Should the UR nurses do insurance reviews? What are some role suggestions?

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The vagueness of your question has stunned us to silence.

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The vagueness of your question has stunned us to silence.

LOL

OP:

Please be more specific so that we can help you out.

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Specializes in Med surg, cardiac, case management.

At our insurance company the UM nurses review clinical data and do approvals. The CM nurses coordinate care.

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Where I work um nurses do everything. Review for medical necessity, discharge planning and care coordination, all while sporting a census of 25-30.

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Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr.

OP, have you ever worked as a Case Manager either inpatient or outpatient? Have you ever performed discharge planning, chronic/specialty planning, UR, etc.? Have your ever managed Case Managers?

Your questions are not only vague but they have led me to believe that you do not know much about Case Management. However, your posts read as if you are tasked with re-organizing a department of which you know nothing. Thus, you may need much more guidance then this forum can provide. Go off line and perform research.

Talk to your staff, your peers, and read about various models that work for your facility and what is not working. Learn more about the government policies that impact our practice. Learn your facility's role in your local area. Learn the expectations of insurance companies and their reimbursement rates. Grow your knowledge that way and you may have a better idea of how to re-organize your department.

On the other hand, another forum that may be of some help is the Nurse Management forum. Those nurses (many of them) have managed various departments forever....: Nursing Management. Good luck!

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Specializes in Med surg, cardiac, case management.
Where I work um nurses do everything. Review for medical necessity, discharge planning and care coordination, all while sporting a census of 25-30.

I only have to do CM, we have UM nurses to do necessity, authorization, etc, but my census is up to 250

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Does your facility also have a Clinical Documentation Program as well?

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Specializes in Neurovascular, Ortho, Community Health.

If you have one position to do UR, CM, and DCP, be prepared for your hospital to lose money or have a good appeals dept. because they probably will be so busy dealing with IP issues that their utilization reviews will be poor. Speaking as a review nurse for an insurance company, you can tell which hospitals have nurses who know UR and which ones have hospitals who have nurses that are overworked or don't care and hence bring in more denials. It may seem like a "cheap fix" to ball it all up but in the long run it may cost you.

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Also my other question would be do you at your job use inter quail or Milliman? that will also help with decreasing denials for commercial companies as well as Medicare, Medicare replacement policies as well as Medicaid, I have been doing UR for 14 years. We use inter quail as well as EHR for patients who do not meet inpatient criteria. this will also help when you have RAC reviews as the Feds are trying to recoup money when patients are billed in the incorrect status

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We use Interqual here and E.H.R. at our facility. EHR has been fantastic in helping with RAC Reviews.

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Do you find it hard to prioritize when you have all of those roles?? Trying to find out where the NQI and quality measures fit in for our group...

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