What is UTILIZATION REVIEW?

I was a UR nurse for a health insurance company, and we processed referral requests from provider offices (primaray care physicians, specialists, DME companies, home health agencies, etc.). We provided review for many types of insurance such as HMO, PPO, Medicare, and Medicaid---all carried by the one insurance company. The type of the insurance the patient carried determined what process we would take to "authorize" (or "approve") a request. The most common requests were for visits to specialists, DME, surgical procedures, diagnostic tests, and home health visits. Some types of insurance did not require authorization for requests. In other words, if a request came in for a patient to see a specialist, and the patient had PPO, no referral request was necessary, so no "authorization" from the insurance company was needed.

When we received a request for surgery, for example, we would review the medical records to see if medical necessity had been met (using Milliman and Robertson, Medicare, or Medicaid guidlelines), then research to see if the specialist performing the surgery and the hospital or facility was in the health insurance company's network. Next we would check to see if the patient's contract with the insurance company covered the requested services. If specialist or facility was not in the compnay's network, or if the surgery had not met criteria, we would contact the requesting provider and ask for the info we needed, or ask that they choose a facility in network. If the requesting provider was not able to furnish what was needed for authorization, we would send the request to our medical director for review, and he would approve or deny the request.

As far as pay, I made approx $3.00 more per hour working as a UR nurse than as a hospital floor nurse.

Thank you for the great explanation. What kind of nursing does one have to do to get into such a position? Do they require other types of experience as well?

We were required to have 5 years of hospital experience for the position. However, I noticed this was waved on occasion if we were short-staffed or if the applicant had a long nursing work history. They did not hire nurses right out of school.

Quick question for the UR nurses. I have come across a UR position in a hospital setting. How is that different from the insurance companies? I have been a cardiac nurse for 18 years with the last 7 being a charge nurse. I have relocated to Colorado and do not want to go back to floor nursing. I basically need a day job with weekends and holidays off b/c my 4 yr. old will start Kindergarten this year and I need to be available at night as my husband works nights.

I would like to apply for this position, but would like to have a clue as to what I would be doing before I jump in.

Any advice???

UR in the hospital setting is responsible for making sure the patient does not outstay his welcome, or his insurance coverage. For example, an insurer will allow X amount of time for each diagnosis code. The UR nurse will review that record to determine if that patient is getting appropriate care related to that code. If there are other issues, or extenuation circumstances, they will communicate this to the insurer. The insurer will only pay for approved days and services. After that, the patient receives the balance of the bill, which, in all probability, will never be payed.

So, to sound quite stupid, is this an interesting job, a stressful job?? I can see alot of unhappy doctors and unhappy patients banging on the UR office door debating who will punch me out first. I have worked in Tele for 18 years and I have to say that I have run into more than one very unhappy doctor and I prefer not to go back there. I certainly do not want that to be part of my daily life. Do most hospitals have UR departments where these things are discussed amongst several nurses or are you on your own? I realize that there are manuals and written info to help, but just want to be sure that this is something I might enjoy before I actually send the application. I think I understand what you are telling me, but certainly you don't have to do this for every single patient in the hospital??? Is it just if a question arises about a procedure or what??? Anything you can tell me will help. Just trying to make an educated decision. My last job was extremely stressful. I DO NOT mind work. In fact, I prefer to be busy for my entire work time because it makes me feel better about what they are paying me and gives me great job satisfaction to believe that I am helping people. However, there is a fine line between being busy and over the top unsafe!!! Just want to be sure. Those of you who have done UR, was it satisfying work? Something that you can go home and feel good about? Or did you lay awake at night wondering if you had denied care to someone who would have truly benefited from it? Just wondering. I am very patient focused. Will that get in the way of being good in the UR dept???

I did U.R. for the NYS Department of Health, New York City back in 1976. The legislature had passed a ruling that all nonemergency Medicaid admissions had to be pre-approved. And that all ER admissions had to be approved within twenty-four hours(during the week) or forty eight hours on the wekend. We were based in various hospitals around NYC and had a set of clinical guidelines to base our reviews on. In 1978 I went to Downstate, Brooklyn, as an administrative assistant and one of the departments I was responsible for was U.R. We were on the floors every day reviewing both new admissions and continued stays. Once a week, the U.R. Committee met. If a patient was in danger of having a further stay disallowed, his attending and he were notified, in person and by letter. Either could appeal the decision but rarely did. DRG's had come into existence by then.

I also lectured at the medical college to medical, nursing, pt and ot students, about the facts of reemburishment and their responsibilities for providing necessary written documentation. I rarely had a problem with any of the attendings or the senior residents. There were a few junior residents that thought they knew more then I did but they soon found out where they stood. Hospital U.R. can be a demanding job. If your Committee supports you, half the job is done. If they are weak, forget it.

Woody

Meantobe: The docs would not hammer you, they know you are not the one making the rules. If a patient really needs to stay, UR nurses are pretty good at extending visits by updating coding or communicating with payers. They can be great patient advocates.

utilization management brings money to the hospital or cause the hospital to lose money. yes, it is stressful, because audits are based on rule based clinical indicators of illness that focus on each individual patient's clinical presentation. a level of severity of illness (si) and level of intensity of service (is) must be met each day to ensure payment to the hospital. if the patient does not meet si or is, the clinical data is sent to a physician (usually faxed to the insurance companies physician advisor) and the physician will review the medical record and get back to you to either approve or deny a patient day or stay in the hospital. if the physician denies the service, the utilization calls the primary physician and tells them the patient is not meeting criteria for inpatient admits. at that point, you will probably get a physician angry. then you go deliver the denial notice to the patient, and get them upset.

each year, the criteria for inpatient admission get harder and harder to meet. some hospitals have selected interqual or mm criteria for guidelines. plus, medicare and each of the medicaid programs have different criteria. each insurance company has their own different criteria. the um nurse, must keep up with all these criteria's or the hospital will not be incompliance with one or all the variables.

keeping up with all the changes can take its toll on a nurse stress-wise. to cut cost, hospitals are now dumping case management in with utilization management; therefore, the nurse is expected to perform both specialties with no mistakes.

Daytonite and Ksilty- you are both a wealth of information. I guess that I have been at the bedside and in a charge nurse role for 18 years and I am ready to make a change and just scared at the possibility of making a change and being totally unhappy. I know that many people do this and when it does not work out, they leave and find another job. I am one of those people who stays at the same job until a move out of state forces me to find another job. Just want to find something that I will love, will be very good at, and where I can make a difference for the company that I work for.

Thanks for all of your great info. At least now, I understand what this job entails. I think I can at least make an educated decision about applying for it.