10 Things I do not like about the Utilization Management Job

For physicians, for any job we take and for any field that we choose, there are always a few things that we like and t there are a few things which we do not like.
In this article, I will try to explain some of the things I do not like about utilization management job.

The first and foremost thing that I do not like about the job is that I have to sit on the chair for several hours day after day. As physicians we know that this is not good for our help in the long-term.

The second thing that I do not like is the denials from commercial payers. Denials are inevitable but it gets too stressful if there is a lot on any given day. We have to review the denials, prepare for the peer to peer and actually talk to the medical directors. The more the denials, the higher the workload and the higher the stress.

One thing that I do not like is the time constraint especially status determinations that need to be made as soon as possible. This is more related to the part-time jobs if working for an organization which support the hospitals where the status determinations have to be made with what ever information is available at that time and move onto the next case as soon as possible. This is especially true if we have to take status decisions early in the day and not knowing how the clinical course will be the rest of the day.

The fourth thing that I do not like is that the guidelines used by different insurance companies are different. Some use MCG guidelines and some use InterQual guidelines. If we are working for the hospital, the hospital may not have both guidelines available to us which makes it difficult during the peer to peer review.

There is always a pressure to reduce observation numbers/improve revenue by reducing costs when we work for the hospital or increase denials when we work for the insurance companies. No matter how hard we work, there is always a pressure to improve even more.

The sixth thing that I don’t want to say that I do not like it but I can say that it can be difficult for insurance medical directors to deal with some physicians when they do not understand the language and criteria used in utilization management world during peer to peer reviews. Almost every physician in Utilization Management hate doing peer to peer reviews.

Sometimes the patients can put pressure on the attending who in turn will reach out to the physician advisors to change the patient’s status to inpatient status based on the request from the patients or their families. We should not change the status unless we believe strongly that the change in the status is justified based on the patient’s severity of illness, intensity of treatment and length of stay.

Regulations can change periodically and we have to keep up with those new regulations to take proper decisions regarding the status of the patient’s admission. Recently, commercial payers were asked to follow 2 midnight rule strictly and also frequently the ‘Medicare inpatient only list’ is updated and we had to keep up with that.

Keeping track of peer to peer reviews can sometimes be confusing. Certain medical directors call at the timings outside of your requested time intervals. Sometimes, they want you to call back only at certain time only and if you forget to call at that narrow window, they will uphold the denial.

Last but not the least, long length of stay patients status determinations can be very difficult and doing their peer to peer review with commercial payer medical directors is even more difficult 100s of pages. This can get very stressful to eyes and the brain.