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Biomedical subjects

Mary Ellen Murray

Publications and source records attributed to Mary Ellen Murray.

8 recordsLinked to original sources
PubMed2005

Responses of hospital utilization review staff to reimbursement denials.

Utilization review (UR) is a strategy used by the managed care industry to monitor and control utilization of health care resources. The concurrent UR process requires that hospital staff report clinical information to payers, who either certify or deny reimbursement. Conflicts may arise when hospital staff disagree with denial decisions. The authors analyzed the various responses of a medical center UR staff to payer denials and found that although denials were not frequent, they were perceived negatively by hospital staff. Improving and standardizing communication among providers, payers, and patients is one means of reducing conflict and frustration in the event of reimbursement denial.

Academic Medical Centers↗
PubMed2003

Denials of reimbursement for hospital care.

Much of the negative perception of managed care focuses on fear of denials of certification for reimbursement. This study examined more than 50,000 concurrent utilization reviews completed over a four-year period (1998-2001) at a large teaching hospital. The results showed a denial rate of less than 1.5% of all patients reviewed, higher denial rates among certain clinical services, higher rates of reviews among certain services only partially explained by volume of admissions, and a lack of patient criteria to receive care in the inpatient setting as the most frequent reason given for denial.

Concurrent Review↗
PubMed2003

An exploratory cost analysis of performing hospital-based concurrent utilization review.

OBJECTIVE: To determine the costs associated with conducting concurrent utilization review, a utilization management strategy widely used by the managed care industry. STUDY DESIGN: A production process model focusing on resource utilization. SUBJECTS: The 29 clinical services of a 500-bed academic health center were aggregated into 9 clinical groups. A random sample of at least 15 reviews per group was studied. METHODS: Time sampling and cost analysis methods were used to determine the cost to the hospital of conducting utilization review. Component activities of the process were identified and analyzed to determine differences among clinical services and among the component tasks of the utilization review process. RESULTS: In 12 months, 13 126 reviews were completed in an average of 15 minutes 41 seconds. Across clinical groups, the average total time of each review ranged from 11 minutes 18 seconds (medical group) to 19 minutes 4 seconds (pediatrics group). Significant differences existed among clinical service groups for the activity of preparing for conducting the review, with the pediatrics group spending more time than the cardiology and oncology groups. The total cost of the process was nearly dollar 166 000 annually. The average cost per review was dollar 11, the average cost per patient-day denied was dollar 478, and the average cost per patient denial was dollar 1592. CONCLUSIONS: These figures are conservative in that they do not include the payer component of the costs, which could be as high as the hospital provider cost. Given a denial rate of < 2% and the high cost of the process, it may be beneficial to investigate alternative processes for conducting utilization review.

Academic Medical Centers↗
PubMed2002

Separate, yet united.

A management council can help nurses from various settings of a facility deliver unified care, including inpatient, home health, and surgical services. The University of Wisconsin Hospital's approach can facilitate a management council at your facility.

Hospitals, University↗
PubMedDate not supplied

A test of mental health parity: comparisons of outcomes of hospital concurrent utilization review.

The Mental Health Parity Act of 1996 had as its goal the equity of coverage of mental health care and physical health care. The purpose of this study was to examine the outcomes of hospital concurrent utilization review as a measure of the progress toward the equity goal. The study examined 4 years of denials of certification for reimbursement by payers of inpatient care (1998-2001). Psychiatry was first compared to clinical services with a like number of annual admissions and then compared to clinical services with a like number of concurrent reviews. For each year, psychiatry had the highest numbers of cases denied and patient days denied. The most frequent reason for a psychiatric denial was that the inpatient benefit level had been exceeded. There was only one instance, in 4 years, when this reason (benefit limit exceeded) was given for a patient with a physical illness. This study provides evidence of the current inequity of reimbursement for treatment of mental illness.

Hospitalization↗
PubMedDate not supplied

A model for economic analysis.

The production process model is proposed as a way to guide economic evaluation of health care projects, programs, technology, or research. The model is illustrated with data from the development of a home care computer intervention.

Cost-Benefit Analysis↗
PubMedDate not supplied

Clinical and fiscal outcomes of utilization review.

Concurrent utilization review (UR) is both a quality improvement tool and a cost containment strategy used by managed care organizations. The UR process requires that providers (hospital staff) communicate clinical information about hospitalized patients to payers who evaluate the appropriateness and medical necessity of the planned care. Payers then make a decision whether to certify the care for reimbursement. This study provides data to indicate that denials of certification have little impact on clinical and fiscal outcomes of patient care.

Case Management↗