Utilization Review for Addiction Treatment – Limelight
One of the most daunting tasks for those seeking help for a substance use disorder (SUD) is navigating insurance benefits. The mechanism for presenting a potential client’s case to an insurance company to obtain authorization for treatment is called a utilization review. At Sanford, we recognize this process is not just an administrative effort. In fact, the human element is key.
Imagine you are ready to deal with a substance problem that is negatively impacting your life. Imagine also, that your heartfelt call to a treatment center, which could be met with bureaucracy, is instead answered with informed and helpful alternatives. Reputable treatment centers will make the administration process seamless. And they will work with you to determine your best course of action. Whether you are privately paying, utilizing regular insurance benefits or other options.
Which brings us to the subject of our Limelight Interview. Jeanne M. McTernan, MA, OTR/L, is a 20-year occupational therapy veteran. She has worked in hospital-based settings at all levels of care, including utilization reviews with hospital case managers. And as Director of Billing and Utilization Review at Sanford, she brings a wealth of knowledge (and empathy) to the process of entering treatment.
In my position, I work with admissions, clinical, and medical staff. Because of this, I have an opportunity to see all the pieces. I have a behind-the-scenes view of Sanford from the first call to admission to discharge.
Jeanne M. McTernan, MA, OTR/L, Sanford Director of Billing and Utilization Review
Utilization Review for Addiction Treatment – Limelight Interview: Jeanne M. McTernan
SH: Let’s start with – what do you do?
Jeanne: Technically, my title is Director of Billing and Utilization Review. But my job at Sanford is to create/manage an internal billing department. I work to get our potential clients admitted to treatment. I am responsible for medical records reviews on the clinical side. And I take care of billing, verification of benefits, collection of services, posting payments, etc. I feel like my years as an occupational therapist really helps me in this job.
SH: Why did you become a therapist?
Jeanne: To help others through difficult periods and challenges in their lives. To be a part of helping others gain hope, courage, and the tools to use to live a meaningful life.
SH: Why did you become an occupational therapist
Jeanne: I wanted a profession that would utilize my undergraduate education (math/science), while staying in a helping profession. So I chose occupational therapy because of their philosophy to treat the whole person. In other words, instead of looking at the functionality of a knee (for example) as a physical therapist would do, we look at the person and their lifestyle and what they will need to do to with the knee to maintain that lifestyle. And I always had an interest in substance use disorders. My master’s thesis was: Screening for Substance Abuse: patients who present with physical injuries or medical conditions.
SH: What do you think is the key to recovery?
Jeanne: A solid foundation from which to grow, mentally, physically and spiritually. And you need a support system. Recovery takes persistence – stick-to-it-iveness. You have to get up when you fall down. It’s not the fall that defines you, it’s the ability to get up from the fall.
SH: Well said. What about the pitfalls?
Jeanne: The pitfalls are people, places and things – not having a plan or coping skills established to manage when something negative does happen.
SH: What is the “fun” part of your job?
Jeanne: Following a client from admission to discharge, and celebrating their success!
SH: And the most challenging?
Jeanne: Learning all the new software and processes…
SH: Do you have a phrase you use often, or overuse?
Jeanne: As long as we are on the same page.
SH: What is your most marked characteristic?
SH: Do you have a motto?
The joy is in the journey.
SH: What about a favorite possession?
My dog Zoe.
SH: And out of curiosity, why are you no longer practicing as a therapist?
Jeanne: Occupational therapy is a physically taxing job. Consequently, after 20 years in all levels of care – acute trauma, suicide attempts, psychiatric, pediatric, inpatient, outpatient – I was exhausted. I thought transitioning to outpatient full-time would be boring; home care felt too isolated; and nursing homes seemed too depressing. So, I spent time in utilization review with hospital case workers. And now at Sanford, I have come full circle. I am one among many who can make a difference in people’s lives.
Thank you Jeanne. SH