Some RT departments have RT driven protocols. This, one would think, would be the ideal way of preventing needless therapies. However, most RTs who work at hospitals that have such protocols note that, "I discontinued the therapy only to come in the next day to see the order was rewritten."
Either that, or senior RTs refused to discontinue un-needed therapies. Why would this be? Well, the answer appears to be obvious: It's called criteria. In order for the hospital to get reimbursement, certain criteria needs to be met. At least this is according to my RT Boss.
For example, if a patient is admitted with pneumonia, most insurance companies (and the government) will not reimburse the hospital unless a breathing treatment is ordered. By golly, if a patient isn't sick enough to need a bronchodilator they don't need to be admitted.
This is funny (irritating would be a better word), because some person in Washington who had no clue what he or she was doing made this decision, when the truth is that bronchodilators have no effect on the inflammation in the alveoli that pneumonia is. Bronchodilators don't even get down into the alveoli.
Regardless, this pretty much explains some of the stupidity. This is why we have a pneumonia protocol (order set I call it) that requires all pneumonia patients to receive Q6 hour Ventolin.
Yes this is frustrating, but it's the way it is.
6 comments:
Where would one find info about pneumonia not being reimbursed by most insurance companies (and the government) unless a breathing treatment is ordered?
I mentioned this article to my instructor and they said they were unaware of such a policy but would love to see any info on it.
Thanks,
RT student
I would like to hope what I write about here is poppycock. If that is the case, then the admins where I work have gone through a lot of needless effort to make sure such "criteria" is met. I've also sat in on various meetings on this topic. However, I have not seen any actual document. I will see if I can get my hands on it.
I will write about utilization review more in a future post. However, there is a published book that lists the criteria that must be met. The criteria may differ from state to state.
I am in Michigan. Could you provide some more information on this book?
I have Googled until my eyes have fallen out & cannot find a book relating to this
Thanks,
RT student
If I see the utilization review lady tonight when I work I will ask her what the name of the book is she carries with her.
It's a book of codes that show what needs to be ordered for that particular disease. It is illegal for the utilization review lady or the hospital to tell the doctor what specifically needs to be ordered to meet criteria. This is why they have order sets so the doctor is reminded of what needs to be ordered. This is one of the main reasons breathing treatments for pneumonia are ordered, even when the patient is not having bronchospasm. More later.
Post a Comment