Utilization Review Nursing
Balancing patient care and cost
Utilization review nurses or, as they are often called, case managers, is a relatively new aspect of patient care, although it’s difficult to imagine now what we would do without them. The role merges several functions once handled by social workers, discharge planners or the physician. In times past, patients stayed in the hospital as long as the doctor deemed necessary, having whatever procedures might be useful. Going in for a good rest when nervous exhaustion threatened a person’s health was fairly common.
But that is no more. In the current climate, every day in the hospital depends on not just patient diagnosis, but also insurance reimbursement and community practice. Major diagnostic procedures, hospitalization, surgeries and discharge plans receive prior approval, or not, and length-of-stay negotiations can rival United Nations’ debates. From beginning to end, the person who oversees all this is the utilization review nurse.
Phase One: Precertification
Several phases of the process involve different types of evaluation. To begin, there is precertification. The provider, which might be a hospital or a physician, contacts the insurer for authorization for care. They speak to someone like Kimberly Champlin, RN, PHN, BSN, who is a medical management nurse lead for a WellPoint office in California.
Using their grasp of clinical medicine, she or one of the several nurses working with her examine policy provisions and clinical guidelines and determine if the proposed treatment is covered. Follow-up calls to clarify the intricacies of each case are common between reviewers and providers, and patients can make direct inquiries for status check. Champlin’s extensive background in home health, hospice and maternal child health gives her the broad understanding to be a successful review nurse.
She and her colleagues have a standard load of 40 cases per day and try to give decisions within a day or two. The shortage of nurses endemic throughout the profession affects the workload at WellPoint, too. Despite that, Champlin says, “I am really happy doing what I do.” The intellectual challenge and advancement opportunities are ample reward.
Phase Two: The Patient Process
Later, during hospitalization, both the hospital’s UR nurse and the inpatient case manager for the insurance company make periodic, usually daily, reviews. Together, they follow the patient from admission to discharge, making sure the current level of care is optimal. Almost from the beginning, planning is under way; as soon as the patient no longer requires acute care, he or she moves to a less intensive setting, whether it be home, ECF, rehab or the like. What everyone wants to avoid is denial of care, or a patient who returns home too early only to come back.
Eileen Bohan, RN, works for the small community for-profit Marina Del Rey Hospital in West Los Angeles. She has focused on UR for 15 years with prior experience in the cardiac catheterization lab and ICU. Her move to UR, like Champlin’s, came when she was looking to balance family obligations with a full-time career, and for that this nursing specialty was perfect. It is almost always a Monday-through-Friday position, without weekends or holidays. Bohan’s interim experience in risk management and patient advocacy, plus her bachelor’s degree in health science, made the transition natural.
Now her days are filled with keeping track of 20-25 patients on a telemetry unit, knowing their particular medical problems and living situation in detail, and understanding how their specific insurance will provide what they need. Physicians are the third leg of the stool, because, ultimately, orders for care, discharge or transition come from them. “Two constants are always on my mind,” Bohan says. “Severity of illness and intensity of service.” Does the patient’s diagnosis justify the care given? Could they recover just as well in a less acute setting?
Discharge planning starts almost as soon as she eyes a new patient’s face sheet. Between the diagnosis and the insurance, or lack thereof, she already has a pretty clear idea of what steps to take.
Not all patients can assist in their own planning, and then families need to share in the process. Clearing up faulty perceptions about insurance and community resources requires careful education. Frequent misunderstandings give rise to questions like, how is Medicare Part A different from Part B? Why does custodial care not qualify for insurance reimbursement? Why do I have to leave this hospital, which I like, to go to one I don’t?
This interaction with patients and families provides some of the greatest challenges of the job and some of its greatest rewards. Many patients are very grateful for the help in navigating the system, others much less so. You need thick skin and a sense of humor in a job that offers the potential for competing interests. And, of course, some tasks are more onerous than others. Bohan’s favorite has to be the requirement by Medi-Cal that she document at least 10 different facilities and their responses every day when she is seeking to transfer a stable patient to a properly contracted facility.
Phase Three: On-site Management
Lisa Davis RN, CCM, is Bohan’s counterpart with the insurance company CIGNA. Davis provides on-site case management, going to two hospitals daily, usually to review four to six patients. She also provides telephonic coverage for an additional 15-20 patients in cases where the hospital does not allow insurance representatives on site. Her niche is general admission patients; there is a separate team of case managers who follow oncology, transplant, neonatal and catastrophic injury patients.
Like Bohan, Davis is conscious from the time of admission to discharge planning, helping to set up facilities and vendors who contract with CIGNA for continuing care. Knowing that she is helping clients get home and stay home safely is one of her best rewards.
The greatest stress? “It’s got to be keeping track of so many patients,” she says. “Trying to stay on top of things.” It is a heavy workload, but one that’s well compensated. The nurses interviewed for this article all agree that pay is comparable to hospital bedside nursing, if not better.
And while Davis’s company does not offer financial incentives for her advanced certification, it did provide tuition money for her prep class and reimbursement for her test costs after she passed what was “the hardest test I have ever taken — eight hours long.” Additionally, CIGNA’s professional development program offers opportunities for advancement through the certification process.
Phase Four: Claims
Suzanne Hanson, RN, BSN, works at the end point of the utilization process. Her job is in Sacramento as the supervisor in the provider appeals unit of Medi-Cal, part of the California Department of Health Services. This places her at the last step before judicial review — in plain language, a lawsuit. Along with 22 nurse colleagues and several physicians, she handles appeals from providers on claims that Medi-Cal previously modified or denied.
The request for reconsideration can involve something as simple as a medical supply company seeking reimbursement for a wheelchair to an appeal by a facility for review of 300 days of hospitalization. There is an expedited service for simple requests, but reviewing an almost yearlong hospitalization can take considerable time. All documentation is hard copy — in other words, no computer files.
Similar to the other nurses interviewed here, Hanson had a varied professional background before choosing to work in review — 37 years total now, including medical surgical nursing, discharge planning, liaison and case coordination. Her career with the State of California began as a review nurse in a local field office where she visited hospitals and coordinated with inpatient reviewers on Treatment Authorization Requests and concurrent reviews.
One distinctive drawback to her current job is the lack of patient contact. Beneficiaries can appeal, but it is a separate fair hearing process independent of her office. Still, Hanson says she derives great satisfaction from “making sure the patient gets the care needed to get healthy and stay healthy,” even if she does it at arm’s length. According to Hanson, budget calamities like that facing the state have no impact on denials. Either something is covered or it is not.
How to Get There
Certification in case management comes through either the Commission for Case Manager Certification or the American Nurses Association. It is useful but not required for advancement in most utilization jobs and is becoming more common.
Nurses in this field enjoy benefits that many envy. For one, the physical toll is much less than hospital nursing. Weekends, holidays and shifts are something of the past, and if you want to minimize travel, this could be it. CIGNA supplies computers, phone lines and everything else to facilitate off-site telecommuting. Davis spends several hours visiting hospitals and then about six each day working from home.
Make no mistake. It is hard work. Yes, you can do it in street clothes, but organizational skills are critical, as are personal initiative and the ability to communicate clearly. In most positions you must be computer literate and have a solid foundation in nursing. While there is little emphasis on the type of nursing education, few review or case manager jobs are open to new graduates, and part-time jobs are unusual.
Elizabeth Hanink RN, BSN, PHN, is a freelance writer with extensive hospital and community-based nursing experience.