Understanding Insurance and the UR Process
Each insurance payer will have some very unique characteristics, but in general they do work in much the same way. Medicare has both an indemnity-type plan and several varieties of health maintenance organizations (HMOs). Medicaid is similar in each state, but each state can have different rules for qualification and administration.
The common factor is that medical costs are exorbitant and all forms of insurance are working to contain costs. Managed care organizations made a strong effort to continue to dominate in some areas, but the administrative costs involved have caused the downfall of many of these organizations, and many have actually gone bankrupt. This left patients out in the cold and physicians with huge unpaid accounts receivable. The trend is swinging back more in favor of allowing physicians to make decisions and to order a reasonable number of procedures and tests, while reserving preauthorization for only select items.
The process of selecting health care options from a network of providers with similar mindsets and goals has also released some of the strangle-holds HMOs have had on the health care field. These issues have caused financial strains on physicians and facilities and have played a major role in producing the nursing shortage. The uninsured population is growing, which is a major concern for all. Health care issues are going to dominate the political arena for years to come particularly since the baby boom generation is reaching retirement age.
Medication coverage has changed dramatically and the high cost of medications dictates a lot of issues for patients. Recent surveys of the elderly have shown that as many as 20 percent have restricted the use of their medications because of prohibitive costs. This can be extremely destructive especially when patients don't understand the dangers associated with adjusting dosages.
Nurses need to understand insurance issues in order to help patients to understand them and to prioritize their medical issues. Most insurance companies have set standards that govern time allowances for hospital and extended care stays. These are based on years of studies of standards of patient care and diagnosis related issues. They are general guidelines, but unless specific instances and circumstances can prove to be detrimental to the patient's health, they will be followed.
In the event that complications develop, the Utilization Review (UR) department will be called upon to review the case individually and to determine if the condition warrants a longer stay. The UR department may be also called upon to review the case in the event that procedures or treatments are being denied by the insurance company to determine their medical necessity. The UR department also reviews cases for quality and performance issues and in the event that any unusual or nonstandard treatment is being provided. Their role is to advocate for quality of care and patient safety.
Patients need to take responsibility for their own health issues. They need to do all that they can to promote wellness. Health care workers need to do all that they can to prevent medical errors and to alleviate cause for litigation. All these efforts will help to reduce medical costs.
Insurance companies will continue to control costs by regulating what they pay for and what they deny. There will be limitations on length of stay as well as on what types of care, tests, and procedures will be reimbursed. With an indemnity plan, there may be fewer restrictions whereas with an HMO, usually prior authorization is required. This can delay treatments and procedures.
The focus of health care will be on the patient learning to care for himself. He may not have the luxury of aftercare or home care visits. You may need to instruct him in how to care for his complicated surgical wound at home. You won't want to begin instructing thirty minutes before he leaves the hospital. That is why it is important to begin your discharge planning at admission. The patient will be well versed and more confident in his own care if you do.
Discussion of aseptic technique and standard precautions should accompany every dressing change along with signs and symptoms of infection such as odor, redness, or fever. You could say something along the lines of, “I'm glad to see that your wound is healing nicely and without any odor or redness. You don't have any fever, which is also a good sign.”