LVNs may support UM reviews but may not make clinical recommendations or UM determinations
Independent practice associations (IPAs) delegated for utilization management (UM) are responsible for ensuring that clinical reviews, recommendations and determinations are performed only by appropriately licensed professionals acting within their scope of practice. Licensed vocational nurses (LVNs) may support UM activities within their scope of practice but may not make clinical recommendations or UM determinations.
What you need to do now
IPAs delegated for UM must comply with California law and state regulations pertaining to LVN roles and responsibilities.1 IPAs should review staffing, workflows and documentation practices to ensure all UM recommendations and determinations are made by appropriately licensed clinicians.
Specifically:
- Ensure policies and procedures support compliant licensure for those conducting UM review and making determinations. Review UM workflows, policies, job descriptions and documentation practices.
- Confirm LVNs are limited to roles within their scope, such as collecting and organizing information for clinical review.
- Ensure UM recommendations and determinations are made only by appropriately licensed clinicians.
- Review UM documentation to ensure it does not indicate an LVN:
- Made a clinical recommendation or determination.
- Provided a clinical opinion for another reviewer to approve.
- Approved, denied or modified a clinical UM determination.
- Update workflows, training materials and staff responsibilities as needed to maintain compliance.
Activities LVNs may not perform
Under California licensure requirements, LVNs may not:
- Analyze, interpret or evaluate clinical information.
- Make clinical recommendations or UM determinations.
- Approve, deny or modify UM determinations.
- Provide clinical opinion for another reviewer to approve.
Compliance implications
Delegated IPAs must maintain UM programs that comply with regulatory, contractual and delegation requirements. Delegated UM activities are subject to ongoing oversight and audit. Failure to align staffing, workflows and documentation practices with licensure requirements may result in audit findings, corrective action plans or review of delegated responsibilities.
¿Tiene alguna pregunta?
Relevant sections of the Wellcare Provider Manual have been revised to reflect the information contained in this update as applicable. The manual is available online.
If you have questions regarding the information contained in this update, contact 866-999-3945.
1 Per the Business & Professions Code: The California Business and Professions Code describes the practice of vocational nursing as “the performance of services requiring those technical, manual skills acquired by means of a course in an approved school of vocational nursing, or its equivalent, practiced under the direction of a licensed physician, or registered professional nurse …” (CA, BPC, 2859).
The California Board of Vocational Nursing and Psychiatric Technicians does not allow decision-making by its licensees, only data collection or following the explicit directions of a registered nurse (RN) or physician on a per case basis. According to the Board, any LVN occupying a position that requires nursing skills or knowledge must adhere to this guideline.
This information applies to Independent Practice Associations (IPAs).
