freefalling

Who benefits from a top-notch UR program? Everyone! And who suffers when a UR program is subpar? Everyone! 1. The patient. Getting the right care at the right time at the right level makes for a healthier person, moving through the continuum of care as appropriate for their condition/acute episode. This doesn’t just happen, it requires oversight. Too many cooks in the kitchen can lead to failures at many levels, which the patient ultimately suffers for. Potential for errors, nosocomial infections, or poor discharge planning leading to failures at home, or poor coordination of care post-discharge resulting in communication breakdown amongst multiple providers, etc. again – who really suffers? The patient. The patient also benefits financially from someone managing the level of care – if they’re at an Observation level, their copay may be one $ amount, if at acute IP it may be 3x that. Or vice versa – I’ve seen high copays for OP/Obsv and zero if the patient is admitted. Not that it’s your job to know a patient’s benefits, but by always ensuring proper utilization at least they are being billed appropriately according to their plan. Hospital/procedure/medication waste costs the patient out of their own pocket. 2. The payer (insurance). UR is cost savings, both up front (the hospital bill), and in the long run (an individual who received the right care/right time/coordinated, focused, appropriate care etc. will cost less money over time by reduced prescriptions, hospital readmissions, multiple specialist claims, repeat/unnecessary testing). Insurance companies expect that their members are being managed appropriately while hospitalized. 3. The provider (aka facility). Proper utilization leads to less waste, which hospitals get fined for. Hospitals get fined for readmissions. Hospitals, SNFs, LTACs, etc. have accreditation standards they must meet, and UR helps meet those and avoid costly issues. UR reduces denials from payers (pt staying longer than is medically necessary, thus not receiving $ they could have received with another appropriately sick pt in that bed). UR helps facilities avoid denials for admissions by having MDs change IP to Observation – better to be correct and receive Obs money than be incorrect and receive zero money from a denied inappropriate acute IP admit. UR helps facilities recognize when they could be billing for higher level of care/services than what the MD documented (ex: higher reimbursement for use of SIRS admission dx vs. simply stating “Fever, leukocytosis”). All facilities are different, some have split out teams that include strictly UR, then MSW’s, then CM’s, then DCP’ers, then Clinical Documentation Specialists, etc., but any/all of the functions above in 1-3 could feasibly be lumped into one UR position. Effective UR requires wearing many, many hats and being aware of how pretty much everything affects something else – either positively or negatively. The patient, the facility, the payer, the government, they’re all intertwined and no one is an island. Good luck in your interview, UR can be fun!

Too late to edit my previous post, so I'll add here: (and this is still assuming the interviewing company is a WC insurer) On second thought, #1) may be that they would want you to do an official denial as "other payer primary/responsible", or deny as ineligible as the injury is not work-related and the person doesn't have industrial coverage. Just in case a hospital or provider of some-sort tries to submit a claim at a later date there would be a denial on record so Claims doesn't accidentally pay. But, still not understanding why the company would even be involved if the person isn't insured by them, unless it's a company that has both commercial and WC policies. Or, then again, they could both be trick questions and the real answer they want is "I'd look it up in the company's policy manual and see what the correct procedure is" LOL :grn:

I agree, need some clarification - your questions sound as if they are coming from the payer side - is your interview with an work comp insurance company? If so, I worked WC/Ins many years ago, and the first things that popped into my head were these: 1) Refer the injured worker to their commercial coverage. 2) Refer the injured worker to the Claims Dept. Or, if it's a strict no-contact & you can't even tell him that, I'd call the atty's ofc and provide the appropriate Claims number for them or the IW to call directly (RN Case Managers have little/nothing to do with claims disputes). Again, I'm winging it here because the scenario is a bit confusing to me, as well as what I would do may be severely outdated. I agree with PP, I doubt a company would nix you based on your responses to these questions, people new to CM would not necessarily know how to answer. Good luck to you!

Yes, of course it is not a CM’s job to make someone meet criteria, but it is a CM/URRN’s job to identify when they do - which can, at times, be a difficult process. I respectfully disagree that one should “NOT look around”. If someone is new to the IQ concept, how else will they know what subsets and tiny little details in each should be looked through and ruled in or out? And what data they even need to gather? Not all patients fit like a puzzle piece in a condition-specific subset, especially in this day and age when everyone has comorbidities that can factor into their need for hospitalization. I certainly hope my post did not imply that anyone should ever, ever “make” someone meet IQ, assuming “making someone meet” implies documenting untruths about a patient’s presentation. The PP is correct, they either do or they do not, hence my comment about not being able to click a box in clear conscience. I do stand by my sentiment that it is the CM’s responsibility to absolutely rule in/out the fact that they do/do not meet IP, (another hence), why I do “look around”. Regarding the book, perhaps I’m old-school, but I want to be able to see everything right now. I find the keyword search to be less than helpful at times (hardcopy index in alphabetical order is much more efficient). I find it a waste of precious time clicking into a subset, clicking open every level of care, clicking open every + tree, and if I can’t find something or I was in the wrong place, starting all over somewhere else. With the book, I can eyeball straight down the page in 2 seconds and move on. I also like being able to flip directly to the Review Process tipsheets in the front while I’m in the middle of a review, otherwise I’d have to back out of my review and open another screen. To each his own, I just thought it was a worthy tip for someone just learning the process.

Hello! Not sure what kind of unit/floor you’ll be working, but yes eventually things do begin to feel intuitive after you’ve seen X-number of the same types of conditions/patients. It does take time, and just when you think you’ve got it all figured out and you can “IQ” someone in your head, they go and add revisions mid-year or change the format completely . Regarding your 15d LOS with 8 different issues, I find the Extended Stay subset easier to use than the condition-specific because there are no time limits (no actual # of days attached). If he’s still there after 2 weeks, chances are you’ll find something in the ES subset that will work. The problems I run across most frequently are: ~ Getting a pt to meet Acute when the doc changes them from Observation (unless something has happened in the past 24h that changes their story, wouldn’t they have met Acute yesterday? And if they didn’t, chances are they won’t meet today either, especially now that they’re stabilized) ~ A pt almost meets but the criteria point is just a smidge off (Creatinine isn’t >1.5x ULN but everything else matches – can’t click the box in clear conscience) ~ When a pt no longer meets any criteria but doesn’t technically meet the Discharge Screens or there’s just not a safe DC plan available for this pt (variance days can only get you so far) Does your facility provide official IQ training? It’s a complex system, but is very doable once you get the hang of it. I prefer the actual book rather than the implanted software, it’s easier to flip pages and hunt around when you can see it all right there – especially if you’re new to the process and you’re not even sure what’s all buried in the program. It’s a learned skill that just takes a while, you’ll get it, good luck!

Just to muddy the waters... What IF, instead of a 79 yr old woman s/p CVA with no long-term hope of an independent life with - limited mobility (requiring hoyer lift in/OOB into a recliner where she watches TV, listens to her classical music and reads the paper on a daily basis) - the need to be pushed around by others in a w/c for the rest of her life - limited ability to express herself (requiring extra effort on the part of those around her to understand her wants/needs/desires), but may be able to say a few words such as "yes, no, not now, oh, ok", etc. and recently began saying a few new words - inability to feed herself (requiring the assistance of others to manually feed her or the use of a fdg tube) - requiring assistance with incontinence was actually… a 12-year-old girl with a rare genetic mitochondrial disease with no long-term hope of an independent life with - limited mobility (requiring hoyer lift in/OOB into a recliner where she watches her Maleficent DVD, listens to her Mylie Cyrus CD and has help reading her Facebook page on a daily basis) - the need to be pushed around by others in a w/c for the rest of her life - limited ability to express herself (requiring extra effort on the part of those around her to understand her wants/needs/desires), but may be able to say a few words such as "yes, no, not now, oh, ok", etc. and recently began saying a few new words - inability to feed herself (requiring the assistance of others to manually feed her or the use of a fdg tube) - requiring assistance with incontinence (the video is something else) Father's pageant dance with his disabled daughter touches hearts - Parents - TODAY.com I agree with Susie2310, sometimes we may be too quick to "hospice-ize" people and forget who they are.

This was my initial thought as well – an untreated UTI can go south fast, especially in an elderly patient. 79 yr old ladies tend not to eat or drink that much to begin with, and if her TFs have just been DC’d, it’s not likely that her nutritional status (and fluid balance if not taking enough PO liq) is up to the task yet, in these first few days beginning a real diet, to fend off potential urosepsis or ARF. Plus, UTI’s have a way of making elderly people loopy (ALOC/AMS), so now is also an unfortunate time to be trying to get a competence eval. She may not be at her cognitive baseline with an underlying infection going on. Not to mention the grief she is experiencing with her loss. Lost her husband + unable to clearly communicate/make wishes known + UTI + no meds + no TF + probable inadequate PO intake + uneducated family + MD that (IMO) appears to have given up too quickly = horrible, perfect storm. I’m disappointed in the MD that came to you with tears in her eyes and told you to DC the TF and stated no abx for the UTI. This does not seem to be the patient that should have simple Rx withheld (it’s Macrobid, for cripes sake, not Levophed), and makes one wonder if she explained Advanced Directives/POA to the sons in a way that they understood what it actually means (see Esme’s very first post, pg. 1). At what point does deciding against such a simple treatment become “neglect” (in an otherwise non-terminal individual with a thus-far unmeasured cognitive deficit, and has not been deemed a hospice candidate)? I’m asking because I admittedly do not know. I see plenty of hospice patients admit to the hospital with UTIs and hip fx’s that are treated, and go right back on hospice service when they are discharged. If the MD is also concerned with the ethics of the healthcare decisions being made, is she planning on moving this forward? What do her Progress Notes state?

A comparison between your employees’ documentation and hospital records is a slippery slope indeed. You’re assuming that a hospital CM/SW documents the details of every conversation had with an insurance CM. In reality, with staffing as it is, facility CM/SW’s have as little time available to them as your employees. “Doing” overrides documenting any day, and specific details are undoubtedly left out of charting. They may even not have the chance to document that a conversation happened at all. No one wants to wade through a book written by the last CM with details like, “Call received from insurance CM Susan requesting verified demographics, faxed copies of discharge summary/instructions/new medications, patient’s home situation and what type of post discharge support will be in place, wanted to know if f/u appts have been made and when they are scheduled”. On a busy day, the best some may hope to get entered might resemble, “Choice form completed by pt, chose XYZ HHC, insurance authorization # 123456 for SNV x 3 obtained from Susan CM, faxed orders to XYZ HHC, await reply on ability to staff”. That’s it. Somewhere in there all those questions from the ins CM may have been asked and answered, but it’s not likely to be documented. Keep in mind that hospital CM documentation is for the benefit of the patient and hospital, not to show support of someone else’s work. Short of recording every outbound phone call to a hospital (and then listening to them all), what type of an audit can you implement to verify particular questions were or were not asked of a hospital CM? It would be unfortunate if your employees were audited and potentially disciplined based on what a hospital CM did or didn’t chart that day. You are correct, it is likely the information will not match, but that’s not to say your nurses are falsifying their documentation. A more troublesome issue may actually be that, based on your employees’ streamlined documentation, you appear to have jumped to the conclusion that they are not being truthful, and are looking for ways to “catch” them by auditing hospital medical records. Perhaps they are also caseload-overwhelmed and would rather spend their time participating in the discharge plan itself than documenting every detail. Why so little faith in your case managers?

hello, I'm new to the whole anti xa lab protocal and have a question. I had a nurse at work tell me one thing and another nurse tell me something else.. When do we actually adjust the dose? Do we do it from the time the lab was drawn or from the time the lab is back? Example: The draw time is 0800. The lab is drawn. In our facility it needs to be shipped out, so we don't get them back for a couple of hours. At 1000 (for ease of figuring) the lab is back and the heparin needs to be adjusted. Six hours from now the lab needs to be drawn, right? So 1600. I say it has to be drawn from the return time, which would be 1000. Another nurse I worked with said it was from the draw time. I'm so confused.