Controlling Costs and Changing Patient Care? The Role of Utilization Management (1989) / Chapter Skim
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Appendix E - Summaries of Committee Site Visits to Utilization Management Organizations
Appendix E - Summaries of Committee Site Visits to Utilization Management Organizations
Pages 253-281
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From page 253... ...
~. The sites were selected to convey something of the variety hat currently exists in utilization management.
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From page 254... ...
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.
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From page 255... ...
The organization believes in intensive involvement of physicians in the review process, in the importance of informal communication among physician advisers, and in seeking cooperative relations with providers. The office is small, and much of the monitoring, sharing of information, and revision of procedures or criteria tends to emerge from the informal communication among nurses and physicians.
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From page 256... ...
Services include preadmission review; admission review and concurrent review for medical, surgical, and psychiatric cases; case management; second surgical opinion; disability review and workman's compensation review; and hospital bill auditing. The organization has developed a detailed set of administrative policies and procedures and comprehensive clinical screening criteria.
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From page 257... ...
If the patient needs additional time in the hospital, then the continued-stay review process continues until the time of discharge. If the nurse reviewer cannot approve a case based on the criteria, he or she will refer the case to a physician adviser, who must call the attending physician or document that they have made a reasonable attempt to discuss the case.
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From page 258... ...
Physician advisers are local practitioners who spend about 3 hours a week conducting reviews out of their own offices. Their decisions are monitored to see how often they uphold a nurse reviewer's recommendation to deny certification.
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From page 259... ...
About 5 percent of the referred cases are denied by the physician advisers. appeals may be made for consideration by a second physician adviser.
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From page 260... ...
Information used for medical necessity determination includes all available clinical data and also the narratives for x-ray and lab wore This company is at the high-tech end of utilization management in both computerization and telephone systems. It strives for a paperless process from initial phone call until discharge, except in those instances in which case management is involved.
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From page 261... ...
It offers clients a wide selection of tandard reports and will prepare ad hoc reports as clients request. The staff uses internally developed criteria that they base on InterQual End Professional Activity Study lengths of stay, but nurse reviewers and physician advisers can make exceptions based on clinical judgment.
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From page 262... ...
A subsidiary of an insurance company, it now offers preadmission review, continued-stay review, second surgical opinion referrals, discharge planning, disability and rehabilitation management, vocational rehabilitation, hospital bill and provider auditing, and case management. It covers 8.5 million lives for large and small companies, insurers, third-party administrators, and self-insured employers.
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From page 263... ...
They work in the company's office 1 day per week; one physician adviser is on-site each day. Management suspects that nurse reviewers are more aggressive than physician advisers in negotiating lower lengths of stays or use of outpatient care.
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From page 264... ...
If criteria are met, reviewers may approve the admission; they call back on the day prior to discharge to verify the discharge or conduct continued-stay review if further days are requested. About 5 percent of the cases are referred to physician advisers.
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From page 265... ...
Nurse reviewers can certify admission based on established criteria and accepted medical practice and can negotiate with attending physicians regarding the appropriate level of care. If that fails, cases are referred to physician advisers.
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From page 266... ...
The organization plans to phase out the use of this panel in favor of a team of on-site physician advisers. Telephone calls from physicians, hospitals, or patients can trigger the preadmission review process; no forms are needed.
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From page 267... ...
Forty percent of cases are referred to physician advisers, who negotiate changes and ultimately approve about 98 percent of the cases that are referred to them. Sometimes physician advisers can approve a case based on information provided by a nurse reviewer, but usually the physician adviser contacts the attending physician to discuss the case.
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From page 268... ...
The organization contends that concurrent review is more effective with physician participation and that preadmission review is unnecessary in staff model organizations. The emphasis is on collaboration with the attending physician when conducting concurrent review and case management.
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From page 269... ...
About 250,000 of the cases are within the state, a figure that represents 60-80 percent of the discharges within the state. It offers preadmission review; concurrent and retrospective review; outpatient review; discharge planning; some quality-of-care reviews and fee reviews; physician profiling within the state; and long-term-care, chiropractic, obstetrical, and disability reviews.
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From page 270... ...
The PRO has about 23,000 physician members, but most reviews are conducted by about 200 physicians, who work out of their own offices. Physician advisers ordinarily make their decisions based on the information provided by the nurse reviewer and rarely contact the attending physician, unless the case has been appealed and is being reconsidered.
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From page 271... ...
Concurrent review begins on admission and continues every 2 days thereafter. Nurse reviewers work on-site at the hospital, review medical charts, and may negotiate with the attending physician.
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From page 272... ...
Medical necessity standards for about 12 medical procedures have been developed by the utilization review and quality assurance committee. If criteria are not met, the nurse reviewer refers the case to one of the two supervisors or to the medical director, who is a full-time employee in charge of the utilization review program.
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From page 273... ...
They may certify or deny a case based on their own clinical judgment. They may decide on the basis of the record provided by the nurse reviewer, or they may call the attending physician.
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From page 274... ...
(2) Most medical admissions are emergency admissions, the necessity of which is evaluated only through concurrent review.
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From page 280... ...
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