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Expect more from Us – A Utilization Rant

Working in the behavioral health revenue cycle management field behind the scenes performing utilization review and utilization management, advocating for those struggling with Substance Use Disorder and Mental Health Disorders has its challenges.

I chose to write this for its therapeutic value; although I do hope to get the attention of my colleagues to see if they are experiencing some of the same frustrations I do.  I have often thought of creating a supportive blog or platform where Utilization Review Professionals can share dissatisfactions, disappointments and exasperations over what are sometimes jaw dropping denials for patients struggling with potentially deadly issues.  It could also be a forum to discuss successes, as we know there are many of those as well.

Baffling are comments such as “we know this case, multiple treatment attempts- they will be fine in intensive outpatient” and “don’t expect a long length of stay, she is young she will bounce back. “   And my all-time outlandish award goes to “expect a step down at next review” – have you ever heard this and thought to yourself, “but I haven’t even provided the clinical for this review, how are you able to future trip my step down?”

These comments coupled with the denial letters received after a Peer Review make for further fodder. I do hope everyone is reading them. Personally, I can hardly recognize the clinical that was pulled out of conversations and used as rationale to deny a level of care. In most cases the information cited in the denial letter does not remotely represent the clinical information that was relayed to the doctor and it scarcely resembles any clinical documentation in the patient chart.

I often wonder if the physicians and clinicians at the insurance companies understand that comments such as “he is not homeless; he can sleep in his car” or “she is able to function day to day” after the patient attempted suicide the previous day, is homeless and also experiencing paranoid thoughts, could be considered discriminatory and stigma – possibly at its worst? That their oath to “do no harm” applies whether they are working in an office or working for an insurance company.

As I express my frustration, I would also like to convey that no matter what obstacle we face, an arrogant physician, a cranky care manager, a lax insurance payer, an indignant supervisor, we can’t give up on trying again and again and yet again to help those that are currently unable to help themselves. And further, we must always “Expect More” from those who can.

Although exhausted, we must pursue integrity. That takes stamina and the willingness to never give up. Our company tag line is “Expect More” – we never fall short of that; we give much more, that I can say with certainty.  We love what we do, we do what we love. We believe, that if you do not believe that a patient can get well and turn their life around then this is not work that you will be happy to do. I hope to see the day that the care managers of the insurance payers demonstrate the same belief.

At Integrity Billing, we celebrate victories such as overturned denials and appeals by ringing a bell every time those claims pay.  These are the types of things that make our day. Therefore, we are here.

Expect More.

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