Former patients and their families express gratitude for utilization review team members02/15/23 11:00:am
Comprised of 72 dedicated individuals, the utilization review team at Rogers works with insurance companies to obtain initial and ongoing authorization for treatment, in addition to handling appeals and claims issues. As made evident in the above quotes from former patients, family members, and employees, one of the most important parts of the job is patient advocacy.
“Unfortunately, insurance companies will sometimes determine the patient’s symptoms and treatment plan at the current level of care no longer meet their medical necessity guidelines,” explains Jeanette Osborn, manager, utilization review. “They decide the patient can be treated at a lower level of care, despite the clinical recommendation from Rogers’ medical staff and treatment team. Even after discharge, the UR team is oftentimes still advocating for patients by working through their appeals and making every effort to get denied days overturned.”
Shannon Boling, executive director of utilization review, says Rogers’ care advocates spend a lot of time educating clinicians at the insurance companies about our clinical protocols, especially in our specialty programs.
“It’s almost like speaking a different language,” Shannon says. “Over the last 20 years, I’ve seen improvements. Insurance companies have developed separate eating disorder criteria and have started to create ‘either/or’ requirements, meaning either there is a safety concern or significant impairment in functioning. But we still have to take the information that’s documented in the chart and translate it to the insurance company’s language. For example, we can’t just report what exposures are on a patient’s hierarchy without first explaining that this is a list of functional impairments as a result of anxiety.”
Shannon is proud of her team and all they do for patients and their loved ones.
“I have overseen UR and case management teams for multiple organizations, and the UR team at Rogers is second to none,” she says. “Their passion for patient advocacy goes above just getting authorizations. They talk with patients and families to help them navigate the insurance process so that they’re able to focus on what is most important: their treatment and recovery.”
Scott Johnson, executive vice president of administration, shares Shannon’s praises.
“I consider it to be an honor to work alongside our utilization review team members,” Scott says. “Day in and day out through their advocacy work, they help to ensure our patients can focus on their treatment and recovery versus navigating the complexities of insurance coverage. The team has done a wonderful job supporting one another coast-to-coast, especially during times of high stress. A big thank you to all members of the utilization review team on behalf of the thousands of patients whose lives and care you have positively impacted!”