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!