What is UTILIZATION REVIEW?

KrysyRN, BSN · May 18, 2007

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.

azzurra29 · May 18, 2007

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?

KrysyRN, BSN · May 18, 2007

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.

meantobe · Jan 5, 2008

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???

Katie82, RN · Jan 5, 2008

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.

Daytonite, BSN, RN · Jan 5, 2008

the ur nurse works for the business side of the health industry. it is the ur nurses responsibility to ensure that the facility is going to be paid for the services that the facility is going to provide and that the patient does not receive more service than they are entitled to. in order to do this the ur nurse has to be very well aware of the medicare and medicaid rules of reimbursement for services and the various rules of the different medical insurance companies for reimbursement (payment for services rendered to a patient). some ur nurses work for one insurance company exclusively. others work for a facility like an acute hospital and must be aware of the reimbursement policies of many different insurance companies. if they know that medicare or an insurance company is not going to pay for certain services it is the ur nurses responsibility to make that known to the patient's physician and the patient before the services are given so there is no misunderstanding about who is going to pay for the service and exactly what services are going to be allowed. there are very strict federal laws about this. hospital ur nurses are commonly used to screen for medicare services. the reason is because medicare, unlike medical insurance companies, does not pre-approve medical procedures. the facility is presumed to know what medicare will and will not cover. the ur nurse's job was born when drgs (diagnostic related groups), the way acute hospitals are paid for medicare patients, came into being as a way to avoid over utilization of services provided to the patient beyond what medicare was going to pay for. in other words, it is an accounting strategy to help facilities not overspend accidentally.

meantobe · Jan 5, 2008

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???

woody62, RN · Jan 6, 2008

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

Daytonite, BSN, RN · Jan 6, 2008

primarily in the hospital setting you are making sure medicare rules are being followed in the delivery of care to medicare beneficiaries and medicare standards of care are being followed. this requires knowledge of those rules. they are listed on the cms (center for medicare services) website. this website is massive. medicare strives to provide quality service to those who use it. they are just very strict about placing the responsibility for billing and collecting payment on the facilities and not on the patient.

i'm sure that if you take a ur job, your boss will explain this to you. the doctors are pretty well aware of this too. they would have heard it from the administrators, their own medical staff officers, the ur people and the medical records people. they just can't admit a patient with some medical diagnosis without proper documentation. it's all about the physician's documentation to support what is in the chart. this is a side of documentation that you, as a hospital nurse, have not been aware of before. the ur nurses have the blessing of the hospital administration on this. because medicare hospital patients are paid by a lump sum (drgs), it is extremely important that the doctors have adequately documented and kept to the medicare rules. if medicare denies a claim, the whole lump sum for a patient's hospital stay is denied and that can be thousands of dollars that a facility will lose on one patient. you will also work with the medical records department on this because they are the ones who will actually code these charts and send off the bills. part of the ur nurses job is the help the doctor document so that maximum reimbursement will be obtained from medicare during the billing process. medicare patients have become the bread and butter of the acute hospitals. they bring in a good deal of he revenue for the hospital. however, based on how the doctor's have documented their findings can determine which drg category the patient gets placed in. i wish i could explain drgs to you better, but they are a complex thing that medicare came up with to pay for hospital services. i just spent a semester learning about maximizing drg payment for hospitals as a coder and the nuances are quite profound.

ur is done for the medicare patients, primarily. you may also need to do it for certain patients with medical insurance that the hospital has contracts with. you would be taught the terms of those contracts and what to look for in the care of those particular patients. the whole idea is to stop the doctors from keeping patients in the hospital longer than required in order to save the hospital money. however, if the patient needs to be hospitalized, they cannot be denied hospital services. the doctors have to be good in their documentation to support the need for further hospitalization. again, this is where the medical records people help the ur nurses out if need be. medicare is very clear about making sure that medicare beneficiaries get the best care possible.

ur is focused more on what the doctor is doing and documenting and not so much on the patient. as i said, it is primarily an accounting concern. if you want to stay clinically focused on patient care, then i would recommend that you go into supervision (not management). you can stay in the clinical area as a supervisor and directly affect what is going on with patient care. a ur nurse is a business and administrative support position and not really a nursing job although nurses are generally hired into these positions.

Katie82, RN · Jan 6, 2008

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.

ASSEDO · Jan 7, 2008

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.