Date of Award
Doctor of Nursing Practice (DNP)
The Center for Medicare and Medicaid (CMS) seeks to achieve cost control by implementing aggressive cost containment mechanisms for an exploding Medicare population. One such mechanism is utilization review, which is employed to limit reimbursement of medical care that is determined to not be medically necessary. The CMS Conditions of Participation mandate that all hospitals determine whether a patient qualifies for an Inpatient or Observation stay. Utilization Review Specialist (UR) nurses were given the Conditions of Work Effectiveness Questionnaire II (CWEQ-II), Organizational Relationship Scale II (ORS-II), and the Job Activity Scale II (JAS II), six months after McKesson InterQual software was installed. The CWEQ-II resulted in the following scores: Opportunity x = 0.83, Information x = 0.71, Support x = 0.91, Resources x = 0.42. Descriptive statistics revealed that the UR nurses perceive themselves to be moderately empowered as measured by the CWEQ-II total score of 14.92 (SD ± 1.23). The Net Present Value was calculated as $1,619,677.93, over a four-year span. Medical necessity denials have increased significantly over the past several years and continue to place hospitals in financial jeopardy. By providing employees with appropriate computer software programs, hospitals can mitigate the monetary damages associated with this particular denial and recoupment, and improve nurse satisfaction and commitment. Empowering work conditions for specialty nurses have positive effects on organizational attitudes and behaviors.
Frazier, Kimberly, "Utilization Review Software: The Impact on Productivity and Structural Empowerment in Case Management Nurses in an Acute Care Setting" (2014). Nursing Theses and Capstone Projects. Paper 16.