Utilization Management

[msladynurse4life, BSN, RN]

Hello, I am a new case manager for Trauma Surgery patients in a large teaching hospital and we are also required to do utilization reviews. I feel more comfortable with the case management duties as compared to doing utilization. Our hospital used to have a dedicated utilization department, but now they are merging the department with case management and most were not given a proper training before the merge. I am still in the orientation phase and having a hard time grasping utilization management. I don't feel that I'm getting enough training with it, because most of the case managers are having a difficult time with it as well. My question is that is there a training course or a program that teaches how to do URs and how can I get more training on it? Thanks!

[nurseprnRN, BSN, RN]

The guidelines you use (Interqual, Milliman, other) should have trainings for you.

At its most basic, what you're doing is providing information on patients in very specific categories-- how many IV lines, how many IV antibiotic doses in 24 hours, frequency of VS, dressing changes, PT sessions, hours of care, how bad was that admission blood glucose, how often did the SpO2 get prescribed/charted, how high was that fever, how many PVCs were there, when was the last admission .... anything that can be counted and quantified, they want to know about, because those numbers add up to "How much reimbursement is that admission worth (if anything)?"

The insurance carriers to whom this information goes at the end of every day have coverage criteria in their policies-- miss a level by a point and the admission will be downgraded (less reimbursement) or denied (should have been under Observation or discharged as outpatient followup, yep. less reimbursement). Can't make that discharge happen by 1pm? Sorry, the day of discharge isn't reimbursed anyway, and the longer she stays and gets care, the more money your hospital loses. So you get to work as a patient advocate to get him the most care possible, but also a hospital advocate to make sure the care the patient is given meets criteria for max reimbursement. Move 'em out.

I grant you, it's a whole nuther way of looking at care. Can be fascinating, can give you the creeps, can ****you off royally, but sometimes it's a lot of fun.

[msladynurse4life, BSN, RN]

The guidelines you use (Interqual Milliman, other) should have trainings for you. At its most basic, what you're doing is providing information on patients in very specific categories-- how many IV lines, how many IV antibiotic doses in 24 hours, frequency of VS, dressing changes, PT sessions, hours of care, how bad was that admission blood glucose, how often did the SpO2 get prescribed/charted, how high was that fever, how many PVCs were there, when was the last admission .... anything that can be counted and quantified, they want to know about, because those numbers add up to "How much reimbursement is that admission worth (if anything)?" The insurance carriers to whom this information goes at the end of every day have coverage criteria in their policies-- miss a level by a point and the admission will be downgraded (less reimbursement) or denied (should have been under Observation or discharged as outpatient followup, yep. less reimbursement). Can't make that discharge happen by 1pm? Sorry, the day of discharge isn't reimbursed anyway, and the longer she stays and gets care, the more money your hospital loses. So you get to work as a patient advocate to get him the most care possible, but also a hospital advocate to make sure the care the patient is given meets criteria for max reimbursement. Move 'em out. I grant you, it's a whole nuther way of looking at care. Can be fascinating, can give you the creeps, can ****you off royally, but sometimes it's a lot of fun.[/quote']

Thanks! We use Interqual criteria guidelines. It's just been a bit overwhelming because I'm learning the case management piece at this time. It's starting to come all together now though and doing the URs helps me in my discharge planning as well. It's a learning process. I got the basics down. It's just learning all the specific details about each insurance payer.