Hospital calls to verify insurance 1. Want to check if they have psychiatric treatment or used up there amount of treatment 2. If no insurance left, they discharge after 23 hours 3. If there is still insurance left, you will be there for 3-5 days of inpatient treatment D) Patient admitted for 23 hours for “evaluation”
1. So the hospital doesn’t have to charge them for a full day in case the parents can’t pay for it and the hospitals don’t lose money E) First 23 hours 1. Patient is evaluated by the physician, social worker, other experts in children (because ESM is designed for adults) because children aren’t mature enough to explain what is wrong 2. Is the child a danger to themselves and others? suicidal? F) Discharged after 3-5 days: 1. But the given medication takes about 2 week o Drugs are effective if administered in the right dose o Patients need to be constantly monitored by physicians to evaluate their response to a drug which is hard to do in 3-5 days o Need outpatient care after hospital stay to keep monitoring but many insurance companies don’t cover this o Problem: symptoms come back so they tend to go back to where they were or get worse after treatment and come back to the hospital G) Discharged if patient exceed yearly limits 1. Most insurance companies limit inpatient stays to 30 days for the whole year III. Internal utilization review A) Similar process B) Except UR occurs within the health care facility 1. Reviewer works with provider, easy to collaborate with doctor 2. UR can approve or deny referrals C) Internal UR is usually a part of a capitated health care plan such as an HMO D)
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- Spring '07
- Sociology, Physician, insurance companies