Discharge Planning Advisor-Payer specialists’ save nurses time

New UR requirement sparks innovative solution

When Birmingham’s Montclair and Princeton Baptist Medical Centers - along with other Alabama hospitals - had the utilization review (UR) function delegated to them by Blue Cross and Blue Shield of Alabama, one of the stipulations was that nurses must perform the review.

"We certify or noncertify admissions based on Blue Cross/Blue Shield criteria, and Blue Cross conducts a quarterly audit to verify our UR activity," explains Laurie Gautney, RN, MSN, CMAC, director of case management.

That meant that a few employees who were certified in health information management and had been performing the UR function for years could no longer serve in that capacity, Gautney says. "They were great reviewers, but Blue Cross mandated that nurses perform UR after a certain date."

One of the recommendations of a consultant hired by the hospitals to do an assessment of productivity and jobs was to delegate certain functions that do not require specific certification, she says. The hospitals followed this suggestion and, as a result, the registered nurse UR coordinator can spend more time doing functions that require her skills and licensure, Gautney notes.

The hospital administration devised a plan that makes use of the former reviewers’ skills and enables the nurse case managers to perform their duties more efficiently, she adds.

Now known as "payer specialists," the employees make calls to insurance companies to get the necessary approval for patient stays, freeing up the case managers to do more direct patient care, Gautney notes. The nurses all have caseloads of between 35 and 40 patients each, she adds, and while not all cases require insurance intervention, most do.

It works as follows, Gautney says: For every patient who is admitted, a face sheet is printed
and sent to the payer specialists, who are equipped with headsets and personal computers.

"They look at [the face sheet] and say, This is XYZ insurance, and I know we need to get a review in,’ so they contact the case manager, who performs the review and sends it back via e-mail," she explains. "The payer specialist will call the insurance company, let it know what’s going on, and receive certification for, say, three days."

Keeping in touch

If, for some reason, the payer specialist needs additional information while on the telephone with the insurer, she will e-mail or page the case manager, Gautney notes. "We use a lot of technology. All my case managers have alpha pagers, which means not only the phone number, but the message comes across. The payer specialist can page a case manager and ask, What is the patient’s temperature today?’"

These employees - there are 3.5 full-time equivalents - are stationed in a room in one location that serves three hospitals, she says. "They all have access to the same computer systems, and we send things to one group e-mail. They all get the information, so we don’t have to worry if one is off that day."

"Everything is dependent on the payer contract," Gautney points out, and "another benefit to these [payer specialists] is that they’re familiar with all that. It keeps us out of the pre-cert denial range."

Before this system was put in place in early 1999, she says, the case managers would have to determine which patients they needed to review, go and review those cases, and then call the insurance company to get certified days. "They would have to wait on hold, or leave a message and [the insurance company] would call back and miss them," Gautney adds. "It took a long time just to do one review."

Another plus to having someone who sits by a telephone, she says, is that the insurance company likes it. The payer specialist can call United, for example, with all 20 of its cases, rather than handle them separately, Gautney notes.

"It’s really been a good thing," she says. "Once in a while, the case managers may have to make a call themselves - maybe because they’re working at an odd hour - and they just hate it. They really appreciate what the payer specialists do. It’s so time-consuming and mundane."

Because the reviews typically come in about midday, the payer specialists have time to do some pre-cert troubleshooting in the morning, Gautney says.

"We were having some difficulty ensuring that we had the right pre-cert number for patients who are scheduled for surgery, magnetic resonance imaging, or outpatient testing," she notes. "The patients would come in, the admitting people wouldn’t stop them - because it’s not really up to them - and they would have the procedure. Then the insurance company would say, We don’t have the pre-cert number,’ and wouldn’t pay us."

What some people don’t realize, Gautney says, is that an insurance company may have authorized a patient’s surgery for one date, but if that date is changed, the authorization is no longer valid. "Or maybe a vaginal hysterectomy is certified, but then the physician does an abdominal hysterectomy and is not pre-certed for that."

What happens now is that the payer specialists get a list of patients scheduled for elective admission or outpatient testing, and call their physicians to make sure a pre-cert number has been obtained, Gautney says. This is typically done about 48 hours in advance of the scheduled procedure, she notes, to make sure that patients don’t show up for surgery and discover there is no pre-cert number.

"If by noon today, they don’t have a pre-cert number for a procedure that is tomorrow at 6, [the payer specialists] contact the physician’s office and try to put it back in their lap," Gautney says. "They don’t want their patient angry, so they either get the number or they reschedule. Usually they just get the number."

When there is a problem with the pre-cert, she points out, "the physician’s office doesn’t usually lose the money - the hospital is out the length of stay." Thanks to the payer specialists, Gautney adds, "we haven’t had any [of those losses] in the past two years."