If a patient’s insurance company is questioning the necessity of continuing an inpatient stay or PHP stay, they will request an MD-to-MD review. UCLA Utilization Review team will page the fellow with call-back information for insurance company scheduler. Call the scheduler and set up an MD-MD review time and date as soon as possible during business hours.
Do not fear! Come up with a good game plan with SW and attending.
- Give brief one-liner for reason for admission and diagnoses
- Criteria for continuing inpatient stay is the same as hold criteria. Emphasize danger to self, others or grave disability. GIVE CLEAR EXAMPLES TO SUPPORT THIS from patient’s behavior on unit.
- Come up with a clear plan for medication changes for the week
- Discuss disposition planning, difficulties with that and any pending changes (i.e. waiting for available spot at residential facility). Reviewers LOVE to hear a clear plan for imminent discharge and will often cover an extra day or two if you have a clear dispo plan.
- If it is your med back up patient, the psychology intern can be present to do the review with you since they know the most about the patient
- Dr. Strober does the reviews for A patients on the inpatient unit
Be honest. They have access to our notes as they do the review. At the end of review, some reviewers tell you about approval or denial and how many days. Some do not. If they do not give an answer, email UCLA UR to ask for follow-up information.
Insurance companies are very difficult, and their job is to partition out limited monetary resources. Do not feel guilty or discouraged if your review is denied. This is very common!
When telling family about results, please do so with help of SW. Stay focused on continued plans for taking good clinical care of the patient. Speak with attending about game plan after denial (i.e. keep in hospital versus a strategic discharge).
If the stay is denied (in part or in whole), the insurance company will still do a final review AFTER the patient leaves the hospital. Contact UR at 310-267-9096 if the reviewer is rude, inappropriate or attempts to give therapy or medication advice about your patient.