Page 254

(PSROs) and academic health centers. Clients are third-party administrators and insurers, and the company sees itself as applying not only its own review criteria but also as applying the more general coverage provisions of clients' benefit plans.

A ''standard" list of procedures that normally should be done on an outpatient basis is used to guide decisions about the appropriateness of proposed inpatient care. The details of the list, however, may vary by client. Allowances for preoperative days also vary by client. Criteria are modified on an ad hoc basis as issues are raised by reviewers. The organization also performs prior review of the medical need for certain procedures, which are a mix of inpatient and outpatient services.

The organization's services are limited to utilization management and include preadmission review, second-opinion screening, high-cost and psychiatric case management, bill audits, claims review, retrospective utilization review, and physician adviser services for in-house review programs operated by insurance companies. Most reviews take place by telephone, and the information is entered into a computer. Some psychiatric case management and most retrospective reviews are conducted at the site of service. Data analysis and program evaluation capabilities are limited because the organization has only its own activity data, not claims data or medical records.

Although patients are responsible for seeing that the prior review process occurs, most calls actually come from hospital staff. All required information is obtained on the first call in an estimated 80 percent of cases. The process works best when the reviewer calls the physician's office after receiving notification of an impending admission. Incoming calls are answered by a receptionist who refers them to review nurses, who collect the information and approve the admission if the criteria are met. If the criteria are not met, the nurses are authorized to negotiate changes with attending physicians. Nurse reviewers are expected to use their own clinical judgment. (It is acknowledged that reviewers sometimes "feed" the criteria to attending physicians to facilitate admission of a patient that the reviewer feels should be admitted.) When nurse reviewers find themselves unable to authorize proposed services, cases are referred to physician advisers, who serve part-time but work from the organization's office. Appeals of denied certifications go to a second physician adviser.

Some clients request that all reviews be done by physicians. In these situations, referrals come to the organization's physician review unit from the client's nurse reviewers by telephone or facsimile machine. Incoming calls are answered by an intake coordinator who enters the information into the organization's data base and prints the referral form for distribution to the appropriate physician specialist. Faxed referrals are handled in a similar fashion. The physician reviewer will, if necessary or requested, call

The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement