Utilization Review - Insurance
Pre Authorization - Utilization Management
Pre Authorization – Utilization Management The medical Utilization Review/Utilization Management (UR/UM) component for Medicare Advantage, Managed Medicaid and other managed care plans is a critical function that requires medical depth, breadth and resourcefulness. Members of SFUR’s physician panel provide Utilization Review for Medicare Advantage plans and Medicaid plans.
The SFUR UR/UM physician panelists that specialize in various managed care plans provide decisions for Inpatient versus observation, authorization of expensive imaging services, authorization of durable medical equipment (DME), authorization of various surgical procedures, and numerous critical medical decisions affecting the managed care insured population.
SFUR physician panelist utilization review costs typically generate 1,500% in cost savings by preventing unnecessary medical care and procedures for the Medicare Advantage and Medicaid plans.
SFUR physician panelists conduct concurrent reviews for members who are receiving care in an inpatient setting from the date of admission and for continued stay approval. Once SFUR have been notified of the admission, the concurrent review process will begin.
The member’s case will be assigned to a physician who will be responsible with consulting with the treating physician (if necessary) and reviewing medical records, to determine the medical necessity of the services being provided. If the review does not meet medical necessity criteria, the SFUR physician panelist will render a decision of whether the stay is approved or denied as not medically necessary.
If the review is for continued stay approval for inpatient acute care stays, a decision will be rendered based on the clinical data and criteria available.
SFUR physician panelists that provide UR/UM are fluent in InterQual® & MCG (formally Milliman) clinical criteria for preauthorization of hospital admissions to determine the medical necessity of hospital admissions.
Diagnoses: Multiple Congenital Anomalies (aniridia, trachea, larynx, bronchus), vision loss, respiratory abnormalities
The SFUR Nurse assessed that the infant was in (at least) moderate respiratory distress. The mother identified that the interventions she knew to use were not helping and additional home care advice was provided. The immediate action they took based on the SFUR Nurse’s assistance significantly improved the child’s respiratory status and avoided a hospital re-admission for continued respiratory distress. Cost without Case Management: $47,823 Cost with Case Management: $ 0 Cost Savings: $47,823
The SFUR Nurse received notification of the plan to transfer this infant to Seattle Children’s Hospital by way of Northwest MedStar air transport from Missoula, MT. The MRC Nurse Consultant understood this to likely be the most expensive way to travel, and the most expensive facility in the state for the infant’s care needs. The plans to transfer were temporarily suspended since the child was in no acute distress. The SFUR Nurse discussed the situation with the parents after locating a closer local hospital, hospitalist, surgeon and dietary team that would accept the patient’s transfer. The proposed transfer to Spokane was accepted by the parents and the attending physician without hesitation.
This change in facility made the travel easier for the parents, facilitated compliance with a closer facility for the return trips and/or follow-up care as necessary, and provided for cost-effective care. The SFUR Nurse then made arrangements for air transport by accessing a discounted provider for significant cost savings. A transfer to a higher level of care, completely different than the proposed transfer request, was arranged by the SFUR Nurse within approximately four hours.
The transfer was able to accommodate rapid examination and surgical intervention for this infant without duplicated studies and/or prolonged evaluations. The transfer also allowed for the response of the SFUR Nurse to arrive at the hospital when the parent was in distress and the care appeared chaotic and disorganized. The SFUR Nurse organized communication between three physicians to review the history and prevent care trials that were already proved to be ineffective in this case.
The care team reassembled and changed the focus of the care to meet immediate needs and the child rapidly improved with the specific care received and was discharged after 5 days of inpatient care (including surgical services). It is most that likely that the hospital would have provided services for at least an additional week to prove growth and development before discharging the family home to Montana. With the closer location to the patient’s home, monitoring of growth and development is accomplished at home with her routine pediatrician and pediatric pulmonologist/ENT providers.
Home health for dietary and tube feeding needs were put in place in Spokane to facilitate teaching and delivery of the equipment, with a backup provider in the family’s local area if more extensive services should be required. The cost for one day at Hospital X averaged at $13,115. The cost for one-day at the recommended hospital averaged at $5,482. Total costs include (at minimum) two weeks of care at Seattle vs. the five days of care at Sacred Heart Children’s. Hospital Cost without Case Management: $183,610 Hospital Cost with Case Management: <$ 27,410> Cost Savings: $156,200
The SFUR Nurse accessed a network for emergency air travel, providing a significant cost savings to the account. The transport was initially scheduled with Medical Transport One; however, the SFUR Nurse was able to provide a cost-effective alternative for this pediatric transport.
- Cost without Case Management: $40,000
- Cost with Case Management: <$15,102>
- Cost Savings: $24,898
The patient received eight cans of specialized enteral formula for her caloric and digestive needs. The SFUR Nurse requested four sample cans to get the family discharged with until her tolerance and effectiveness could be re-assessed.
These 4 sample cans saved the account approximately $168 since the billed amount is approximately $42 per can.
- Cost without Case Management: $336
- Cost with Case Management: <$168>
- Cost Savings: $168
- Total Hard Dollar Cost Savings: $229,089
- Medical Case Management Fees: <$4,439>
- NET SAVINGS: $224,650