Cost Containment Services
Case Study Summary – Utilization Review Cases
The purpose of Utilization Review is early identification of potential high-dollar and high-risk procedures and services. We target and medically manage the plan’s most costly services to determine medical necessity and review the proposed plan of treatment for medical appropriateness, determine whether the services should be provided and if alternative options have been considered that may be less costly and/or more effective.
The Utilization Review Nurse gathers information regarding the nature of the services and the underlying medical problems. After all of the information is obtained, a determination is made regarding the medical necessity, appropriateness, and relatedness of the service, length of stay, number of treatments, etc., prior to certification and according to your established guidelines. There are occasions when review and research indicate the requested services are not appropriate, they do not meet medical necessity criteria or the services are not necessary. By the Utilization Review Nurse making this educated determination, the client may avoid an invasive unnecessary procedure or other services. In turn, this preserves the client’s benefits and co-pays and saves the account from paying unnecessary medical fees.
For Case Study Summaries of cost savings through review by Utilization Review professionals, please expand the links below:
Client 33059: $ 184,064 Savings (Diagnoses: Cervicalgia)
The Medical Rehabilitation Consultants Utilization Review Nurse Consultant’s medical background and knowledge enabled her to recognize that a typical request for spinal fusion and associated requested procedures might not be appropriate for this client. After a thorough record review, it was found surgery did not meet established medical necessity criteria for this diagnosis; therefore, the procedure was determined to be not medically necessary. This determination was confirmed with a secondary physician review by a Board Certified Specialty Physician.
• Avoided spinal fusion professional fees: $ 51,727
• Avoided spinal fusion facility fees: $ 132,799
• Specialty Physician Review: $ (462)
Total Cost Savings: $ 184,064
Client 33223: $ 92,664 Savings (Diagnoses: Displacement of Lumbar Intervertebral Disc)
Diagnoses: Displacement of Lumbar Intervertebral Disc without Myelopathy; Lumbago
A request was made by the provider’s office for spinal surgery for this participant. The MRC UR Nurse Consultant reviewed the clinical documents. She found the participant’s records did not include a referral for surgical intervention. In speaking directly with the provider, it was also learned that there was no fracture and no instability. The direct conversation with the provider confirmed that the request did not meet medical necessity and the surgery was denied. When the participant learned of the determination, she requested additional assistance and recommendations which the Nurse Consultant was able to provide based on her nursing education and background. The patient agreed to follow the recommendations and appreciated the information instead of undergoing another surgical procedure.
• Avoided spinal surgery professional fees: $ 34,104
• Avoided spinal surgery facility fees: $ 59,000
• Specialty Physician Review: ($ 440)
Total Cost Savings: $ 92,664
Client 34278: $ 197,805 Savings (Diagnoses: Spinal Stenosis in Cervical Region)
Diagnoses: Spinal Stenosis in Cervical Region; Backache; Pain in Limb
The provider’s office contacted the MRC Utilization Review Department to request a two-stage neck surgery. The participant would remain in the hospital and have the second stage four days after the first stage of surgery. The MRC UR Nurse Consultant researched multiple criteria sites and did not find where all the procedures and the extended stay were medically necessary. Due to the extensiveness of the requested surgery and the request for the additional inpatient stay, a secondary review by a Board Certified Specialty Physician confirmed the MRC UR Nurse Consultant findings. Again, a requested peer-to-peer conference was conducted and the determination of non-medical necessity was upheld.
• Avoided second neck surgery professional fees: $ 51,134
• Avoided second neck surgery facility fees: $ 147,595
• Specialty Physician Review: ($ 924)
Total Cost Savings: $ 197,805
Client 34556: $ 27,685 Savings (Diagnoses: Tear of Medial Cartilage)
Diagnoses: Tear of Medial Cartilage or Meniscus of Knee
The provider requested an arthroscopic knee repair, however, when the MRC UR Nurse Consultant contacted the surgeon directly, his comments indicated that the knee was stable and there were no indications to meet the criteria for this surgery to be medically necessary. Therefore, the surgery was denied as not being medically necessary and saving the patient from an invasive non-necessary procedure. A peer-to-peer review requested by the participant’s surgeon confirmed the denial determination.
• Avoided arthroscopy knee surgery professional fees: $ 16,555
• Avoided arthroscopy knee surgery facility fees: $ 11,900
• Specialty Physician Review: $ (770)
Total Cost Savings: $ 27,685
Client 35321: $ 96,498 Savings (Diagnoses: Lumbago)
Diagnoses: Lumbago; Spinal Stenosis of Lumbar Region
The MRC Utilization Review Nurse Consultant recognized that the provider requesting the procedure is known to frequently request procedures that are not found to be medically necessary per Standards of Care under National Practice Guidelines. With this knowledge, the MRC UR Nurse Consultant requested additional records which were fully reviewed. After the case was reviewed and still determined to not be medically necessary, the records were forwarded to a Board Certified Specialty Physician peer who agreed with the determination. When the requesting surgeon was informed of the determination, a peer-to-peer conference was requested and again the determination for the procedure not to be medically necessary was upheld. The determination resulted in avoiding a non-medically necessary invasive surgery and a 3 to 4-day inpatient stay.
• Avoided spinal surgery professional fees: $ 38,641
• Avoided spinal surgery facility fees: $ 59,880
• Specialty Physician Review: ($ 462)
Total Cost Savings: $ 96,498
Medical Case Management
Medical case management involves an in-depth management program for participants with catastrophic or chronic illness or injury and helps in ensuring compliance, complete communication, and face-to-face communication with all involved parties. Medical Case Management is defined as the timely coordination of medical care to meet an individual’s healthcare needs and maximize the use of benefit dollars while supporting a quality medical treatment plan. MRCs Nurse Consultant reviews the entire picture of the participant’s health and medical status, problems, necessary treatment, the treatment being given, and alternatives to care. It also includes a review of the cost of services, drugs, equipment, and supplies; price negotiation; and long-term cost estimates.
By providing early intervention and care, and by direct contact with the participant, family, and providers, MRC’s Nurse Consultants have knowledge of the needs of the participant for necessary treatment and appropriate care. By having this knowledge in conjunction with the Nurse Consultant’s education, coordination of care and education to the participant will be provided. In more cases than not, this will contribute to an appropriate treatment plan, fewer medical fees through patient education, and negotiated equipment and care costs.
For Case Study Summaries of how Medical Case Management has preserved benefits for the client and account, please expand the links below;
Client 14396: $ 250,125 Savings (Diagnoses: End Stage Renal Disease)
End-Stage Renal Disease; Renal Failure (chronic); Other Complications Due to Renal Dialysis Device, Implant, and Graft; Diabetes Mellitus; Other and Unspecified Hyperlipidemia; Gout; Essential Hypertension; Coronary Atherosclerosis of Native Coronary Artery; Arterial Fibrillation; Atherosclerosis of Native Arteries of the Extremities with Intermittent Claudication; Other Congenital Hamartoses, Not Elsewhere Classified
The client had been in medical case management for an extended time dealing with the denial of a kidney transplant from facilities and the fact that they could not locate a suitable live donor. The MRC Nurse Consultant continued to provide support, education, and resources to the client and his family until a kidney transplant could be completed, which it was in June 2012, with a kidney donation from the client’s son-in-law. With the MRC Nurse Consultant’s involvement, the client was encouraged to convert to Medicare as his primary insurer – which provided the benefit plan with significant cost savings. Since the transplant, the client is now on immunosuppressant medications that are very costly and being primarily covered by Medicare with the employer benefit plan being the secondary insurer. This provided a great deal of cost savings with coverage of the transplant and immunosuppressant medications.
The MRC Nurse Consultant coordinated with Swedish Medical Center to send all records relating to the client’s recent transplant evaluation to UWA, to avoid duplication of a complete repeat of the transplant evaluation. In addition, the MRC Nurse Consultant contacted six cardiovascular providers to request all records be sent to the UWA transplant director to avoid duplication of cardiovascular testing. Commonly requested cardiac testing prior to transplantation:
• Left Heart Catheterization: $ 11,915
• Left Heart Catheterization prof. fee: $ 1,765
• Imaging, Cardiac Catheterization: $ 1,834
• Imaging, Cardiac Catheterization prof. fee: $ 278
• Injection for coronary x-rays: $ 643
Cost Savings: $ 17,341
The MRC Nurse Consultant has been involved from the beginning with this transplant case. Although the client had the option of retaining his primary coverage through the employer benefit plan (and his preference), the MRC Nurse Consultant was able to demonstrate to the client the importance of him agreeing to Medicare being the primary payer to conserve his private insurance dollars since dialysis and transplant. This is an 80/20 percent savings for the account. In the first year a total transplant treatment will cost approximately $262,000. 80% are covered by Medicare and 20% are covered by the employer benefit plan.
Cost Savings: $ 209,600
The MRC Nurse Consultant has been able to demonstrate to the client the importance of him agreeing to Medicare being the primary payer to conserve his private insurance dollars. The average monthly medication cost is $3,222. Medicare coverage is $2,578 and the employer benefit plan coverage is $644 per month. Medicare will continue to cover the transplant cost for 36 months.
Cost Savings expected for 36 months: $ 23,184
Total Cost Savings: $ 250,125
Client 18531: $ 104,921 Savings (Paraplegic (T4-5) secondary to MVA as child )
Paraplegic (T4-5) secondary to MVA as child; Traumatic Brain Injury; Neurogenic Bladder; Stress Incontinence; Urinary Incontinence; Hypertrophy of breast; Specified congenital anomalies of breast; Intrinsic Sphincter Deficiency; Chronic Urinary Tract Infection; Renal Calculi; Depression
The client was involved in a motor vehicle accident as a child. She suffered from multiple injuries and became a paraplegic from T4-5, as a result of the accident. As a result of her injuries she has had several surgeries and urgent medical needs. This client and family include the MRC Nurse Consultant’s involvement with every detail of the client’s medical care. The MRC Nurse Consultant has been able to ensure the client is seen by PPO providers. When equipment purchases were necessary, the MRC Nurse Consultant presented to the account different pricings demonstrating that the facility was significantly marking up the costs, resulting in negotiations and cost savings. The client and family have been very happy and supportive of the MRC Nurse Consultant and medical case management program sending several messages of gratitude.
The MRC Nurse Consultant identified planned care that did not require inpatient hospitalization; therefore the client was able to return home with appropriate care to recover from an outpatient procedure. The cost of care, if inpatient care was instituted, was estimated to be: 7 days for post-operative infection.
Cost Savings: $ 51,483
The MRC Nurse Consultant provided education regarding IV antibiotics that could be given at home or in an outpatient setting. The MRC Nurse Consultant also discussed the importance of hand washing before and after caring for the open wound.
The MRC Nurse Consultant received a message from the client’s father reporting the client’s irrigation tubing began to leak. The MRC Nurse Consultant recommended that the client’s father contact the physician and determine if the tube could be removed and if the client could continue with IV antibiotic therapy. The physician was called the following day and the client was taken in and the irrigation tube was removed. After consulting with provider at the Mayo Clinic, the recommendation was to discontinue the irrigation tube and continue the IV antibiotics. The intervention by the MRC Nurse Consultant avoided an inpatient admission for post-operative wound infection.
Cost Savings: $ 51,483
The MRC Nurse Consultant researched and identified that a wheelchair purchase for the client was marked up 30% and was successful in negotiating a lower cost.
Cost Savings: $ 1,955
Total Cost Savings: $ 104,921
Client 30279: $ 14,838 Savings (Diagnoses: Epilepsy)
Epilepsy, unspecified; Dyslexia; Complex Strabismus
The client is a young female, who, according to previous documentation, was diagnosed with grand mal seizures approximately three years prior to referral to MRC. The initial seizure was immediately after a varicella vaccination and first presented to a pediatric neurologist at the age of nine years. For the first two years, the client was having seizures three times per year increasing to monthly for the past year, with a change in character to a complex partial pattern. When the client has a seizure, she reportedly becomes unconscious, her body becomes limp, and she is amnestic and holds her breath, and cries in the post-ictal stage (after the seizure). She was started on anti-epileptics in June 2012 without significant improvement. The client has had MRIs in the past that showed questionable asymmetry of the hippocampi. The treating neurologist continued to change medication dosages with little to no improvement in the client’s seizure activity.
The MRC Nurse Consultant discussed with the client’s parents the option of seeking a second opinion, which they agreed to pursue. The MRC Nurse Consultant researched the Seattle Children’s Hospital Epilepsy Program and assisted the family with coordinating care at Seattle Children’s Hospital and obtaining free air travel with Angel Flight. The client underwent neuropsychological testing at Seattle Children’s Hospital on February 14, 2013, and was admitted on February 19, 2013, for inpatient evaluation and continuous EEG monitoring. After the complete evaluation, a medication weaning plan was recommended by the neurologist and this recommendation was given to the client’s pediatric neurologist. The client has been weaned off the seizure medication and there have been no episodes of unconscious-type activity requiring medical attention. The client was experiencing extreme fatigue with unconscious activity lasting up to four hours. The neurologist opined that the client was being administered too much seizure medications and felt a slow weaning process should be implemented, along with further evaluation. The EEG at Seattle Children’s Hospital did not rule out a diagnosis of epilepsy, but the neurologist felt it made the diagnosis less likely.
As of April 9, 2013, there was no new seizure activity reported except for some dizziness described by the client. The client has decreased fatigue and states to be doing much better at school.
1. The MRC Nurse Consultant was instrumental in coordinating care for the client’s seizure activity, as prolonged unconsciousness puts a patient at risk for brain injury, this intervention was vital. The MRC Nurse Consultant assisted the client in obtaining a second opinion at Seattle Children’s Hospital where the neurologist believed the client needed to wean seizure medications.
• A minimum of three emergency room visits for a moderate to high level of care for seizure activity were avoided ($2,677 x 3)
Avoided ER Visits: $8,031
2. Due to the MRC Nurse Consultant arranging for a second opinion, it was determined the medication the client was taking was no longer necessary and was discontinued.
• 6 months of medication costs saved ($847.20/month)
Medication Savings: $5,083
3. The MRC Nurse Consultant made arrangements with Angel Flight to transport the client and a parent at no charge to Seattle for the evaluation.
Cost of travel from Soldotna, AK to Seattle: $ 1,274
Total Cost Savings: $ 14,838
Client 31112: $ 98,094 Savings (Diagnoses: Pain in the thoracic spine)
Pain in the thoracic spine; Lumbago; Closed fracture of dorsal (thoracic) vertebra
The client had been referred for a surgical procedure in an attempt to better manage the pain thought to be a result of multiple compression fractures in his spine. The physician had been continuing the patient on narcotic pain medications in increasing doses and suggested he may have more pain control with a spinal cord stimulator. This procedure would involve two steps, a trial stimulator period and then, if effective, additional surgery for more permanent placement of the spinal cord stimulator.
The MRC Nurse Consultant evaluated the medical necessity of the spinal cord stimulator trial procedure by reviewing the clinical documentation. Additional information was obtained telephonically from the physician’s office and the client to ensure that all information was available and considered. Multiple neurosurgical best practices criteria and medical policies were researched to cross-reference appropriateness for the determination of medical necessity. Based on all the documentation reviewed and the criteria established, the MRC Nurse Consultant appropriately determined that the procedure recommended in this case was not indicated for the client’s diagnosis; it was considered experimental/investigational and therefore not a covered benefit. The client was very appreciative and understanding of the determination and will work with his treating team of physicians to consider alternatives to the surgery proposed. The physician’s office did indicate that they would explore alternative treatments for the client.
As a result of obtaining additional information and researching the procedure, the MRC Nurse Consultant was able to determine that this procedure was considered experimental/ investigational for this client in this situation. Without MRC’s intervention, the ineffective surgical treatment would have been completed and paid as a covered benefit.
Hospital charges and ongoing maintenance charges avoided: $ 98,094
Total Cost Savings: $ 98,094
Client 31199: $ 19,917 Savings (Diagnoses: Acquired Spondylolisthesis)
Acquired Spondylolisthesis; Right L5 Radicular Syndrome of lower legs (with subtle right foot drop); Lumbar Foraminal Stenosis; Polyneuropathy; Hip Pain; Leg Pain; Lower Back pain; History of L4-L5 hardware removal, instrumentation, and fusion on July 29th 2013; History of L4-L5 fusion
The client was referred to Case Management in February 2013. He had an EMG showing evidence of right L4-L5 radiculopathy with both acute and chronic features with a subtle right foot drop. Surgery was initially scheduled for March 2013, but had been delayed for further evaluation after inconsistent findings. The client was not comfortable with undergoing surgery if there is a possibility that symptoms would not be resolved.
The client was unable to carry out activities of daily living without being in significant pain, and could no longer drive his car due to pain; he was not working. In July 2013, it was determined the client would undergo bilateral foraminotomy, fusion, and decompression. The surgery was completed in July 2013, however, the client continued to have pain and discomfort without improvement. The client was referred to Central Peninsula Hospital to have adjustments or repairs made to hardware screws that were used in a prior surgery. Diagnostic testing indicated at least a portion of the hardware was interfering in some way with the spinal nerve; therefore, a procedure was necessary to move the piece of hardware off the nerve in anticipation of relieving this patient’s painful symptoms.
1. The MRC Nurse consultant completed a line-by-line review of the hospital bill.
• Hospital Charges: $ 82,317
• Discounted Charges: $ 74,006
Cost Savings: $ 8,311
2. The MRC Nurse Consultant assisted the client in avoiding at least one emergency room visit for post-surgical pain, at least two office visits for increased complications of healing and recovery, and at least one additional medication to assist the client with pain management.
• Average cost of an ER visit for intractable pain: $ 1,289
• Average cost of an ER physician visit: $ 282
• Average cost of an outpatient visit for an established patient (x2): $ 252
Fees Avoided: $ 1,823
3. The MRC Nurse Consultant negotiated a direct agreement with the surgeon’s office on their surgical fees.
• Surgeon Fees: $ 57,549
• Negotiated Fees: $ 47,766
Cost Savings: $ 9,783
Total Cost Savings: $ 19,917
Client 34556: $ 67,312 Savings (Diagnoses: Crohn's Disease)
This female participant has a history of multiple episodes of abdominal pain, diarrhea, and rectal bleeding. She also has a history of hypothyroidism and morbid obesity. She was scheduled for bariatric surgery when her symptoms intensified. She underwent diagnostic testing and was subsequently diagnosed with Crohn’s disease. The participant was started on medication for her condition but experienced a flare in her abdominal symptoms, which can often be a side effect of the prescribed medication. The participant had an episode of severe abdominal pain in January 2014 and was admitted to the hospital. At the time, she was diagnosed as having acute pancreatitis and gallstones. She underwent surgery to remove her gallbladder.
The MRC Nurse Consultant was able to facilitate an earlier discharge than originally planned, as well as a laparoscopic surgery instead of an open procedure. The MRC Nurse Consultant maintained contact with the participant while in Oregon, Alaska, and during her temporary move to Japan. The MRC Nurse Consultant determined that the participant had Indian Health Benefits, and was able to facilitate the participant being evaluated by a gastroenterologist in Anchorage, Alaska at no cost to the plan. The participant was started on a specialty injectable medication, and her disease process has remained in remission. The MRC Nurse Consultant has thoroughly researched means for the participant to receive her specialty medication while in Japan, and also facilitated the participant being seen by a gastroenterologist in Japan for possible transfer of care. The participant has at times been very stressed with the need to ship the medication, and on multiple occasions, against medical advice, has stated she may stop taking the medication if she cannot receive it in Japan. The MRC Nurse Consultant has been successful in explaining the possible consequences, including probable flares of her Crohn’s disease and potential hospitalization.
The participant was hospitalized for acute pancreatitis along with continuing Crohn’s flare. Due to the MRC Nurse Consultant’s involvement, including education relating to her diagnosis and medications, the participant and her mother felt capable and comfortable discharging home after three days, two days earlier than planned. The MRC Nurse Consultant’s interventions and assurance to the participant that the MRC Nurse Consultant was available at any time, lead to the successful early discharge from the hospital.
Estimated Cost of Hospitalization (2 Day LOS): $ 4,000
The MRC Nurse Consultant questioned the need for an open cholecystectomy, as originally proposed by the participant’s surgeon. After reviewing with the provider, a laparoscopic cholecystectomy was deemed medically necessary. Due to the MRC Nurse Consultant’s intervention, the cost of an open surgery was avoided.
• Open Cholecystectomy: $ 19,447
• Laparoscopic Cholecystectomy: $ 6,793
Cost Savings: $ 12,654
The MRC Nurse Consultant determined that the participant had Indian Health Benefits and as a result, the participant’s two gastroenterology visits, as well as air and ground transportation, were covered by the participant’s SEARHC benefits.
Specialty Provider Visits (x2), including travel and transportation: $ 2,188
The MRC Nurse Consultant facilitated the participant being able to receive her medication while temporarily in Japan. After learning that the participant planned to discontinue the use of Humira, the MRC Nurse Consultant successfully explained to the participant the importance of continuing to take the medication, thus preventing hospitalization for the flare of Crohn’s symptoms.
Hospitalization (4-5 Day LOS) for Crohn’s Disease: $ 44,606
The MRC Nurse Consultant was able to contact the Humira manufacturer and verified the correct handling/shipping means of the medication to determine that three doses of medication received by the participant in Japan, were still safe to utilize even, though the temperature had been exceeded. Thus, unnecessary disposal and additional medication were not required.
Humira (x3 Doses): $ 3,864
Total Cost Savings: $ 67,312
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