Utilization Management Explained
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- เผยแพร่เมื่อ 2 มิ.ย. 2024
- Utilization Management Explained
Utilization Management is also know as managing 'Bed Days.'
When a patient with commercial health insurance is admitted to the hospital, the hospital is required to obtain approval from their health insurance company for payment.
When the health insurance company approves the hospital stay, it only does so for a certain number of days. That number of days is determined by the clinical situation of the patients.
For example, pneumonia may be approved for 3 days and a scoliosis surgery for 5 days.
Only two companies in all of America set the standard for 'Bed Days.' Those companies are Interqual and MCG Care Guidelines.
Interqual is owned by UnitedHealth Group and MCG Care Guidelines is owned by Hearst.
$400B in inpatient healthcare spending is run through Utilization Management every year making Interqual and MCG Care Guidelines VERY POWERFUL companies.
CORRECTION: The St. Louis newspaper is not owned by Hearst.
Sources:
www.changehealthcare.com/clin...
www.changehealthcare.com/clin...
www.doximity.com/pub/monique-...
www.bcbsnd.com/providers/news...
www.mckesson.com/About-McKess...
www.kff.org/medicare/issue-br...
www.healthaffairs.org/doi/10....
www.mcg.com/care-guidelines/c...
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As a nurse trying to transition from bedside to UM this video was extremely informative. Thank you!!!! ❤❤❤
Thank you for watching.
Lp
I am currently working in the health care field. This video was very educational and totally make sense why our health care system is so fragmented.
Thank you for watching and for your comment.
You are great! 3 years being an UM nurse, and I have never heard anybody explaining how the healthcare system works as good as you did. SUBSCRIBING
Super! Thank you for watching.
Trying to become a UM nurse
Im case management now
Any tips or is your company hiring?
@ReeseFuller-rg1vn get connections that are already in the UM field, ask your colleagues around.
Thank you for this. I am a registered nurse who lost her way in corporation-related jobs and wanted to return to healthcare-related jobs. I was applying for UM so I was doing my assignment to understand it before any interviews. Glad I stumbled across your video. Hope I can get the job.
Thank you for watching.
Dr. Bricker, I enjoy every one of your videos. They are so informative and educational.
Thank you for watching.
@@ahealthcarezI’m currently working in Healthcare Finance/RCM, your content helps me to understand the field much better. I’m still working on finding the balance of personal growth and moral conscious, which hopefully when I find my path, my work will provide solutions not adding more cost.
Great video! Keep up the no filter content. I think we need to be honest about these incentives and power structures; only then can we even begin to talk about redesign and progress
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You explained this better than my professor lol. Thanks!
Thank you for watching and for your kind words.
Yes I learned a lot from just this one video
Another great video Dr Bricker!! - thank you!
Thank you for watching and for your feedback.
The best as always, thank you for the knowledge!
Thank you for watching and for your positive feedback.
Wow! Love your real world perspective! Thanks for sharing!🌷
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Awesome video!! Thanks so much. Very clear and informative!
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Excellent presentation; very helpful! Thanks!
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Thank you for this video! I just started my UR RN position and it is so eye-opening how much money is spent for not actual care but behind the scene BS that doctors and nurses and of course patients have to endure.
Great point. Thank you for watching.
I start in UM on 2/27 and all I can say is WOW 😮
Hi Iamnerd I'm currently looking for a UM position, any recommendations for company to look into
Hi @@peachesroyale I'm currently looking for a UM position any recommendations on company to look into
@@rosecharles9617 look at all the major insurance companies or local hospitals ….they hire for UM! Good Luck 🍀
Awesome Video! Thank you
Thank you for watching.
Excellent talk!
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Excellent information and explanation.
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Very nice and elaborated clearly the concept
Thank you for your feedback.
This is a mind-blowing knowledge that was delivered in an exceptionally effective way. I have never met anyone like you who would explain utilization management so clearly and in just 15 minutes. I am also impressed by critical thinking and fresh perspectives that you bring into each video. Seems like that Prior Authorization and Institutional Notification became a burden to efficient patient care. How can we make more competition towards the the InterQual or MCG Care Guidelines? What are alternative options?
Your channel is music to my ears
Thank you for listening… I mean watching. 😉
I’m going into consulting and your videos have helped immensely!
Super!
NCQA - National Commission on Quality Assurance dictates the use of MCG or Interqual. To have a hospital or practice license you have to comply with NCQA guidelines. Thus UM and the use of MCG or Interqual guidelines is part of how hospitals are licensed to practice in all 50 states because of the adoption of the NCQA guidelines to assure "Quality of Care".
Do the breakdown and a video on this please!!!
Also, Medicare uses National Care Determinations / Local Care Determinations (aka NCD/LCD) to determine what is a billable charge and how much those DRG's are compensated at (baseline) {which is adjusted by MSA and other factors} - Medicare Advantage has to follow CMS NCD/LCD unless there isn't one (typical for acute care, atypical for medical device, medication, or post-acute care), if there isn't an NCD/LCD then they allow the use of MCG or Interqual as the guideline because it is "universal" as part of NCQA compliance necessary to obtain an operating license.
Thank you for your comment and the video suggestion.
Patients should know there is a process to appeal insurance denial of extra hospital days. Looking at 20k bill it's worth a try folks.
Agreed. Thank you for watching and for your comment.
Love this!!!
Thank you for your positive feedback.
Thank you.
Thank you for watching.
Not a bad way to end the weekend!
🤣🤣 Thank you for your support.
Thanks for this video and pointing out the facts. I am a case manager (not UM) trying to decide if I want to go into UM. I think I like working with the patients more directly and your video helped confirm that. 😊
Super! Thank you for watching and for your feedback.
Loving your analysis of the financial incentives and systems underlying the hospital! Do you have a topic or know how the UM plays into chronic anemia patients? We’re working on a home transfusion program for HH&H to build a case for a CHC carve-out from the current CMS guidelines due to hospitals around our S. Texas area not meeting the expectations of these DX groups, private and MCR insurances alike.
Or more broadly, the push for HH&H to start performing more emergent care procedures if the healthcare landscape in the region can’t support it. I’m looking forward to your next vid!
That is more a Case Management matter… which is separate from UM.
I’m sorry can’t be of more help.
Thank you for watching!
thank you Dr. Bricker. Would you share insights on how does UM works for Patients that have D-SNP and MMP (Medi-Medi) plans?
Thank you for watching and for your question.
Many hospitals don’t agree to these UM provisions, but Payers don’t care and they control the purse strings. As such, legal action is the only recourse (which is often more expensive than the reimbursement they’re seeking). Payers leverage the costly legal system, exhausting the providers as much as possible, then settle cases before legal precedent can be established.
Good to know. Thank you for sharing.
To make sure I'm following, does the $400B comprise only approved bed days, or is that the total of approved + unapproved? Assuming there is likewise a very non-trivial total administrative costs of all the subsequent appeals of denials, stress on patients & their families, etc...
I only came across your channel recently, but have been rabbit-holing on these very lucid (and sobering) videos since finding it. Thank you.
Approved + unapproved. Thank you for watching and for your question.
Great video doc Would you recommend only paying x amount for a patient
Or is duration of stay UM better?
Great question. Think the former is better.
This is wild ! 😮😮
Thank you for watching.
Livanta makes the decisions on who gets discharged on IMAPD I couldn’t find anywhere that they use this system
what is the difference between utilization management and utilization review? Because it seems alot of their functions seem to overlap
The two are often used interchangeably, but UR done on the insurance side and UM done on the hospital side.
What happened to David Belk M.D., and his book, and website, which all seem to have disappeared?
After this lecture, I'm feeling an undercurrent I can't quite straighten out between Medicare pt care and Healthcare companies, considering Medicare has a cut off dollar amount.
Super! Thank you for your feedback.
You make healthcare makes so much sense again 😂😂😅
Thank you for your feedback.
So why is UM bad compared to DRG? Is it because UM sets their standard “bed days” at a higher than average number of days to recover from an illness? Which in makes more money for the hospital? Or more money for the Insurance companies or both?
UM for insurance carriers sets their bed days based off Interqual and MCG Carr Guidelines. Hospitals do not set bed days. Thank you for watching and for your questions.
Can you consider a conversation on universal healthcare vs our current plan system. I know it's a way out there fanta$y that will probably never happen but just wondering if health care consumers understand how serious healthcare company's lobby for this not to happen, and you're experienced opinion on what that might look like if it ever happens.
Thank you for your suggestion. Great topic!
That is a broad topic, universal health care can mean different things. It can be fully socialized like the NHS, VHA where a single government insurance is the payer and owns facilities and employes workers. Or it can be like Medicare in Canada where hospitals are private but government is single payer.
Hi, Dr. Bricker could you possibly do a video on how to appeal a denial of services, outlining specific steps and verbiage to overturn a decision from the insurance company. Thank you
Thank you for your suggestion.
kick-backs 2 hospital admin.
Thank you for your comment.
Proprietary 🤔🤫. Healthcare surely is Big Business. While I know that, the more I'm watching your videos the bigger my eyes get. And I'm in the hospital business my entire work career.
It’s a very large and messy industry. Thank you for watching.
Medicare is smart, boy did they save BIG on some cash for implementing DRG vs length of stay
True. Thank you for watching.
You are an ex Anthem Inc exec. Why did Anthem RIP OFF employees who gave their lives to the company for their retirement benefits? Told one thing for decades then suddenly a "policy change" just a few years short of retirement. BAIT AND SWITCH.
I have never worked for Anthem. Thank you for watching.
Hi Dr.Bricker! Fantastic video! I sent you a LinkedIn request! Would love to know if it’s even possible to compete with these Utilization Management as a startup and if so how?
Thank you for watching and for reaching out.
Great video thank you.
Thank you for watching.