UR in the hospital

[wincha]

I know this isn't officially case management however this appears to be the best place to post this.

I understand what UR is for insurance companies ie Interqual Guidelines to pay for a level of care or not in the hospital. My question is what UR nurses do working in the department for the hospital. I am assuming keeping track of what the insurance co will pay for, appealing, looking for more ways to get the insurance co to pay ect... any other tasks of UR in the hospital?

Thank you very much for whoever can answer this question.

[CaseManager]

UR in Acute Care Hospitals that I do is to call in or fax reviews on inpatients with a clinical update to Ins. Case Mangers for continued days to stay in our hospital. If it's a perdium with exclusions then you will need to let the CM of the Ins company know that patient is have a proceedure as they will be paying for this. If you get a % as 70 % then usually everything is included, but we have diferent contracts with co. also. Is that clear as mud? LOL! Also Ur is going through your chats everyday making sure the patient meets continued stay by your criteria. Hope this helps or is even wht you wanted! :o

[MaritesaRN]

I know this isn't officially case management however this appears to be the best place to post this.

I understand what UR is for insurance companies ie Interqual Guidelines to pay for a level of care or not in the hospital. My question is what UR nurses do working in the department for the hospital. I am assuming keeping track of what the insurance co will pay for, appealing, looking for more ways to get the insurance co to pay ect... any other tasks of UR in the hospital?

Thank you very much for whoever can answer this question.

Ur used to be just UR. but now the hospital is also using them as case managers. Case manager is not something I would like to go into due to it's scattered multi tasking, and you really need to have a good system intact in a hospital to make this work efficiently. you can do UR in a quality management dept in a hospital.

[MaritesaRN]

Ur used to be just UR. but now the hospital is also using them as case managers. Case manager is not something I would like to go into due to it's scattered multi tasking, and you really need to have a good system intact in a hospital to make this work efficiently. you can do UR in a quality management dept in a hospital

[Straydandelion]

When I was in UR, not only was it working with insurance/CM's, calling updates along with D/C planning but also referrals i.e. risk management, home health, social service. Another aspect was medicare admits and length of stay, delays in treatment/D/C etc. A lot of this also entails discussion with admitting doctors, talking to patient and family if needed regarding plan of care and discharge planning etc.

[MaritesaRN]

When I was in UR, not only was it working with insurance/CM's, calling updates along with D/C planning but also referrals i.e. risk management, home health, social service. Another aspect was medicare admits and length of stay, delays in treatment/D/C etc. A lot of this also entails discussion with admitting doctors, talking to patient and family if needed regarding plan of care and discharge planning etc.

As you can see they lumped up all of these things above....which makes it inefficient. You can not be a jack of all trade and still do the job well. I have been all of the above in separate roles and they are all time consuming.....and they really need to be separate functions. Especially when you are dealing w/ medicaid. Some of these poor patients have no home to go home to and discharge planning from this population is not easy and extremely time consuming, adn this should go automatically to social workers who are trained in community affairs and resources, and the nurses should stick to what they were trained , such as the cllinical aspect or the medical necessity of the stay or procedures done. Risk management belongs to the quality management department, difficult placement with social worker, UR for data base reports for medical necessity inpatient stay of the facility, and simple discharges such as d/c to home w/ DME or a home health visits cango to a separate discharge planner (if the facility is huge) or this can be lumped up as one of the case managers duties ( if the facilty is small) ..............otherwise all of the above role for one nurse is just not going to work......not effectively or as efficient anyway.