Utilization Management Explained

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:

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[dededailyinspiration]

As a nurse trying to transition from bedside to UM this video was extremely informative. Thank you!!!! ❤❤❤

[eunsookswitzer]

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.

[shivamraja]

Can't get any simpler than this! Thank you so much for this easily digestible information!

[synelpt]

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

[amberriley]

"registered non-physician". Man I'd love to see that term come up in court regarding past and future medical charges in injury cases.

[karrienesu]

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.

[amysturges]

Just found your channel and it's so informational! Unbiased and easy to understand. Great work

[Raksh]

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

[bphillips]

Literally, some of the finest content I can recall. Your boldness and authenticity are refreshing. Thank you for exposing this. Please stay safe....

[ip]

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.

[tatianathomas]

You explained this better than my professor lol. Thanks!

[rbnye]

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.

[simplyme]

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.

[lisamaxwell]

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. 😊

[AnonymousTry]

Dr. Bricker, I enjoy every one of your videos. They are so informative and educational.

[ev]

I’m going into consulting and your videos have helped immensely!

[komilakarimova]

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?

[Rob-frit]

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.

[shirlenet]

Wow! Love your real world perspective! Thanks for sharing!🌷

[brindadevik]

Very nice and elaborated clearly the concept