Efficient Utilization Review Documentation

[On The Way]

Hi. I'm working as a utilization review nurse for an insurance company. I'm looking for guidelines on documentation. I don't want to over-document if it's not necessary, especially as we have a quota that few of us ever meet. I don't want to under-document either. We've had no training (nor at my previous company). We get no feedback. I could write a sentence or a novel. Questions are discouraged.

I often wonder what the point of utilization review documentation is for an insurance UR nurse. I understand that a UR nurse from a hospital justifies care/payment. And so documentation has to be provided. But who is an insurance UR nurse providing documentation to/for once we've looked at InterQual to see if the patient meets? Unless the case is going to be reviewed by a medical director because it's not going to meet, I don't see the point of having much documentation.

We insurance UR nurses are not actually caring for the patient. The in-depth information is in the clinicals, should anyone ever want to look. Can we just document how the case meets InterQual and be done with it?

Has anyone struggled with this situation and come up with a good balance between too much, too little, or the minimum necessary? Or actually received training from their company?

Any thoughts/help would be appreciated. I cannot find anything on the internet about this question.

Thanks.

[Been there,done that, ASN, RN]

Can't imagine who you are working for. I do UR and documentation is everything.

There are NCQA, ERISA , and Medicare standards that must be met for accreditation.

[OscarTheOwl]

How can you possibly not get any instruction regarding what to document?

You say not much documentation is needed for a denial, I disagree. This is the time the hospital will file a dispute, your documentation is going to explain in detail why the claim is denied.

The company does not sound conducive to a new UR nurse. Doesn't make any sense to discourage questions. Good luck.

[OscarTheOwl]

Just curious, how many reviews are you required to do in a day?

[TheCommuter, BSN, RN]

Moved to the Case Management Nursing forum for more replies.

[On The Way]

Hi Oscar. They want us to do 20 - 25 cases. I agree with you about the denials. In my post I mentioned (in a not very clear way) that I could see a reason to document more thoroughly for the denials.

Anyone: Does calling for clinicals count as doing a case for you? Does it count as part of your daily quota?

[On The Way]

Hi Been There, Done That. Re: NCQA, ERISA , and Medicare standards that must be met for accreditation. Are these about the actual documentation? Or about timelines and fraud, etc. Do you know what the minimum documentation allowable is?

[Neats, BSN]

I use SBAR notes. Short sweet and capture all pertinent info. If it is a first time/new member then I try to make a more comprehensive note that includes staging of oncology cancers, or other need to know documentation so the next nurse has the information if they want to look, if it is a nurse I trust I use that historical information. If it is ongoing and Interqual is being used as long as there is one great note I just use the interqual, other people can open up documentation if they choose to verify what I wrote if they wish the documentation is there..

[On The Way]

Thanks Neats. I've seen that approach from some of the hospitals. Documenting inside InterQual for many of the notes.