Re: Utilization Review ??'s

[mgerardo]

I am an RN with a BA in Psych. I have been very frustrated trying to find a resource for training in UR. Any suggestions? I would be cool if it were on-line or similar. Thanks

[BBFRN, BSN, PhD]

mgerardo,

Are you wanting to enter the field of UR?

[KrysyRN, BSN]

I am not altogether sure that there are any resources out there to study. I worked in this area for years (years ago), and all of the training, at two different Fortune 100 companies, was on the job. UR involves being knowledgeable about the patient's insurance contract, interracting with the patients insurance companies to discuss the contract and the patients covered benefits, reviewing charts, and interacting with the patients physicians as well as the insurance company physicians for determination of medical necessity or contract coverage of requested services. There is much more, but this is the bulk of it.

When working in UR, I learned about insurance and how each of the products worked (such as HMO, PPO, Medicaid, etc) through trainers at my job who specialized in these areas.

I familiarized myself with the patients contracts by reviewing them with each referral request.

Medical necessity issues were determined by reviewing my companies guidelines (which were based on Milliman and Robertson guidelines and InterQual guidelines). If I was unable to detemine medical necessity for referral requests with the resources given to me, I would send requests to our company's medical director for the determination.

So this is it in a very small nutshell!