Migliaccio & Rathod LLP is investigating whether Independence Blue Cross may have failed to pay overtime to certain utilization review or utilization management nurses whose work consisted primarily of applying standardized clinical criteria to healthcare authorization requests.
Independence Blue Cross employs nurses in utilization review, precertification, auditing, and other health-plan roles. Its current materials state that nurses and medical directors perform utilization-review services and that the nurses performing that work are salaried employees of the health plan.
Independence Blue Cross also confirms that its Utilization Management department currently uses InterQual criteria for multiple categories of healthcare services, including acute inpatient care, rehabilitation, home health, behavioral health, and selected procedures.
Importantly, Independence Blue Cross states that only physicians can issue denials based on lack of medical necessity.
That combination raises questions about whether some salaried nurse reviewers may primarily perform standardized initial reviews while final adverse decisions remain with medical directors.
Nurses May Have Been Required To:
- review hospital admissions or requests for healthcare services;
- organize medical information for review;
- apply InterQual, Independence Blue Cross, CMS, or other established criteria;
- determine whether a request satisfies specified review requirements;
- prepare cases for additional review;
- communicate with providers;
- meet timeliness or productivity requirements; and
- refer medical-necessity denials or other adverse determinations to a physician or medical director.
Independence Blue Cross has previously described a process in which utilization-review nurses apply InterQual criteria and then refer certain cases to an Independence Medical Director for final review and determination.
Why Overtime May Be Owed
Being paid a salary does not by itself eliminate an employee’s right to overtime.
Migliaccio & Rathod is investigating whether some IBX nurses were classified as overtime-exempt despite spending most of their time applying predetermined criteria, following standardized review procedures, and escalating final medical-necessity determinations to physicians.
If these nurses regularly worked beyond 40 hours per week, including completing reviews or documentation outside scheduled hours, they may have been entitled to additional compensation.
Potential Claims May Include:
- unpaid overtime under the Fair Labor Standards Act;
- improper overtime-exempt classification;
- unpaid wages under Pennsylvania or other applicable state law;
- failure to maintain accurate records of hours worked; and
- liquidated or statutory damages.
Signs You May Be Affected:
- You worked for Independence Blue Cross or Independence Administrators as a Utilization Review Nurse, Utilization Management Nurse, Precertification Nurse, Clinical Reviewer, or similar employee;
- you were salaried and did not receive overtime;
- you regularly worked more than 40 hours per week;
- you routinely applied InterQual, IBX, CMS, or other predetermined criteria;
- you could not independently issue certain medical-necessity denials;
- you regularly sent cases to medical directors for final determination; or
- you performed chart review, case documentation, or other work outside normal hours without additional compensation.
If you have encountered these issues, we would like to hear from you. Please complete the contact form on this page, send us an email at [email protected], or give us a call.