What is the difference between hospital and commercial utilization review?

[rearviewmirror, BSN, RN]

Hello my trusty old nurses. No place like here to ask a question!

I am working at commercial side doing utilization review and since I got an opportunity to move over to hospital side, I was wondering if you have experience working at the hospital side doing UR, and what is different between them two: which one you liked, and which one you didn't and what suited you the best.

I will be doing mostly inpatient reviews.

Thank you for sharing your wealth of knowledge!

[Been there,done that, ASN, RN]

It's up to you to interpret and apply the criteria. The difference is... on the commercial side, you don't want the criteria to meet, so payment can be denied.

In the hospital setting, you want the criteria to meet so the hospital gets paid.

It's all a game, I liked the commercial side, so I could work from home.

Best wishes.

[rearviewmirror, BSN, RN]

It's up to you to interpret and apply the criteria. The difference is... on the commercial side, you don't want the criteria to meet, so payment can be denied.

In the hospital setting, you want the criteria to meet so the hospital gets paid.

It's all a game, I liked the commercial side, so I could work from home.

Best wishes.

haha I thought you would be one of those who would reply, saw your id around the ur/cm posts so appreciate your input very much.

I have been on the receiving and reviewing end as well at commercial instead of being on the side trying to get LOS approved, so really curious how the work stress and load will look. I sometimes think hospital UR staff will just shove all the clinical in scanner and just send them and move on, but know that's not it either... wonder if reviews at hospital take longer.