Murray ME; AcademyHealth. Meeting (2004 : San Diego, Calif.).
Abstr AcademyHealth Meet. 2004; 21: abstract no. 1020.
University of Wisconsin - Madison, School of Nursing, 600 Highland Avenue, K6/340 CSC, Madison, WI 53792-2455 Tel. 608.263.6945 Fax 608.263.5332
RESEARCH OBJECTIVE: To examine the responses and attitudes of hospital staff members who receive a denial of certification for reimbursement when providing clinical information for concurrent utilization review (UR). STUDY DESIGN: The UR process requires that care providers, typically registered nurses employed by the hospital, report clinical information to payers, or their representatives. This information is related to the severity of illness of the patient as well as the projected plan of care. Reviewers then make a determination if the care meets criteria of medical necessity and appropriateness and is allowable under the terms of the hospital/payer contract and the individual insurance policy. Care that meets these criteria is certified for reimbursement. A qualitative design was used to study the responses and attitudes of hospital staff members who received a denial of certification during the 12-month study period. Each staff member was asked to complete an audiotaped interview with a research assistant. The taped interviews were subsequently transcribed, and analyzed using the affinity process. The analysis team consisted of 5 doctoral students in nursing and the principal investigator. POPULATION STUDIED: The study was conducted at an Academic Health Center. Interviews with hospital staff were obtained for 99 of the 102 denials of reimbursement that occurred in the one-year study period. Hospital staff who conducted the UR process included nurse case managers (N=18), clinical social workers (N=9), case manager associates (N=8), and additional registered nurses (N=2) who provided part-time support for the UR function. The 102 denials of certification for reimbursement were associated with 26 different hospital clinical services and involved only adult inpatients. Denials occurred most frequently in psychiatry (21), orthopedics (11), neurology (9), transplant (7), neurosurgery (7), surgical trauma (6), rehabilitation (5), and peripheral vascular surgery (5). The remaining 18 clinical services had only 1-4 denials each over the 12-month study period. PRINCIPAL FINDINGS: Key themes that emerged from the data include: (1) Hospital staff refusal to accept responsibility for informing patient or family members of the denial, (2) Protective responses of patient by hospital staff when denial occurs, (3) MD with limited or no involvement in the utilization review process, (4) Initiation of adversarial payer-provider relationship when the payer makes a denial, (5) Occasional recognition that the denial decision is correct and payer/provider cooperative relationship is created, (6) Social issues related to denials, and (7) Feelings of powerlessness of UR staff to affect physician and payer decisions. CONCLUSIONS: Participation in the concurrent utilization review function produces conflict in hospital employees who perform this function. These employees identify themselves as patient advocates in opposition of payer pressures to reduce inpatient utilization. IMPLICATIONS FOR POLICY, DELIVERY OR PRACTICE: This study raises important questions about the responsibility of health care providers to discuss financial issues related to patient care and the potential conflict this causes within the patient/healthcare provider relationship.
Publication Types:
Keywords:
- Adult
- Concurrent Review
- Hospitals
- Hospitals, Teaching
- Humans
- Interviews as Topic
- Managed Care Programs
- Nurses
- Personnel, Hospital
- Trauma Centers
- Utilization Review
- economics
- utilization
- hsrmtgs
UI: 103624054
From Meeting Abstracts