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A Baseball Player and a UR Nurse Go Into a Bar….

Apr
02

A baseball player comes to bat. The pitcher throws four “balls” and the batter receives a walk. The batter is on first base but the box score does not record this as an “at bat”. The walk has no role in the player’s batting average.

In utilization review, many think the most important thing is what you DENY. How many times can you tell the physician he/she can’t perform a procedure…or can’t pursue a particular treatment plan…or can’t do a certain diagnostic test. Some believe that the total value of UR is an aggregation of the things we refuse to approve.

Well, of course, there is great satisfaction (and value) in looking at the spreadsheet and observing what has been requested and what has been denied. After all, the box score is important. But that isn’t the whole story.

Sometimes a physician will ask for approval of a procedure, but our evidence-based criteria indicates that a period of more conservative treatment should be attempted before moving to a surgical solution. In those cases our nurses may say, “Do you want to withdraw this until you complete more conservative treatment?” This lets the physician know that under certain circumstances we can approve that request…but just not now. So the physician frequently withdraws the request and tries a more conservative approach. And there is no entry on the spreadsheet. The physician came to bat but it doesn’t appear in the box score. However, there has been successful management of the case.

Is the patient getting the proper care? Has the physician tried the basics before moving to the more severe? If those things happen, we are all winners. We can help you with that and it won’t always show up in the box scores.

Call us. We can do better.

William Faris, JD
Chief Executive Officer
502-495-5040
william.faris@omca.biz
www.omca.biz

Posted in OMCA