UR by CM a conflict of interest?

[d'cm]

Grntea, posted in another tread: "In our state it is illegal for case management to do UR. Third party administrator (TPA) companies sometimes have two separate divisions for UR and CM, but it's a conflict of interest for the CM or the CM department to do UR on his/her/its own patients."

I have a few questions

What state is that?

Is that just for insurance company CM?

What happened that caused the legislature to enact such a law?

Does anyone else see an inherent conflict of interest (COI)when a CM does UR?

Most states prevent obvious COI like insurance companies incentivizing [COLOR=#333333] medical directors to increase denials but I am having a hard time conceiving of how a CM would be in COI doing UR. I do firmly believe that hospitals (and all providers really)have clearly been put into a position of COI by Medicare rules which say they have to self-police their own utilization while being compensated for quantity of "care". This conflict does seep down to the hospital CM who is delegated to review Medicare admissions for medical necessity and I have been fired for taking that responsibility too aggressively ( from their POV).

[Selfie]

Hi. I think it depends on the type of CM done. I am a CM for different states, and some states prohibit the CM from doing UR in the same state- as conflict of interest-but it is decided state by state. I work for a TPA, and if I have a state that does not allow the CM to do UR, I send the request to our UR department. Every state has different guidelines.

I think in your case, medicare is federally regulated, so my guess is the state guideline rule would not apply.

[nurseprnRN, BSN, RN]

Look at it this way: If the company puts on its UR hat and approves an insurance company's expenditures for a course of treatment, and then puts on its CM hat and bills that insurance company for case managing that course of treatment... that's a conflict of interest. Or, if the company puts its UR hat and denies a course of treatment after instructing the CM not to work for the patient's benefit after the CM's professional assessment indicates it would be beneficial, there's a conflict of interest there too.

MA

All health care, pretty much, is paid by some kind of insurance, and most insurance companies employ case managers or TPAs to provide case management.