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.
Westphal
Judith
J
Clinical Science Center, University of Wisconsin-Madison School of Nursing, Madison, Wisconsin 53792-2455, USA. jawestphal@wisc.edu
Semeniuk
Yulia
Y
Darmody
Julie
J
Pawlak
Roberta
R
Hook
Mary
M
Murray
Mary Ellen
ME
D000046:Academic Medical Centers; D006801:Humans; D007345:Insurance Claim Review; D007407:Interviews as Topic; D008505:Medical Staff, Hospital / Q000523:psychology*; D012051:Reimbursement Mechanisms / Q000458:organization & administration*; D014600:Utilization Review