The Hospital Guide to Contemporary Utilization Review, Third Edition

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The Hospital Guide to Contemporary Utilization Review, Third Edition

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The Hospital Guide to Contemporary Utilization Review, Third Edition

The Hospital Guide to Contemporary Utilization Review, Third Edition, is a comprehensive resource designed to identify utilization review (UR) best practices and provide guidance on developing and enhancing a contemporary UR committee. This book focuses on the latest UR and patient status requirements to help hospitals perform high-quality reviews and comply with regulations in a value-based world.

The book covers a range of topics, including compliance with the UR Conditions of Participation (CoP), legal obligations of a hospital, contract language, and compliant UR plan language, to provide an understanding of the expectations of a UR program. Tips for intradepartmental collaboration are included to guide professionals through the process of selecting a physician advisor and partnering with nurses, case managers, and revenue cycle team members.

This book will help you do the following:

  • Identify the components of a best-practice hospital UR program
  • Describe the legal obligations of the hospital to comply with Chapter 42 CFR 482.30 of the CoP
  • Use the publication as a tool to assess your own hospital’s UR processes
  • Summarize the benefits of a dedicated UR team to promote compliance with the CoP
  • Differentiate between traditional Medicare and Medicare Advantage
  • Facilitate the development of a contemporary UR committee
  • Discuss the pros and cons of the possible reporting structures for UR activities
  • Examine the role of the physician advisor as a member of the UR team
  • Recognize the crucial role of revenue cycle in the work of the UR specialist
  • Recommend compliant language for your organization’s UR plan
  • Describe the components of the revenue cycle pertinent to UR
  • Differentiate inpatient and outpatient payment rules
  • Explain the basics of claim preparation
  • Review physician billing and payment rules
  • Differentiate between national coverage determinations, local coverage determinations, and commercial payer criteria
  • Seek out operational resources to perform high-quality reviews that fully comply with the CoP
  • Explain the connection between a good UR plan and a hospital’s revenue cycle initiatives


Published: October 2021

Page count: 194
Dimensions: 8.5x11 Perfect Bound
ISBN: 978-1-64535-138-2

Table of Contents

Chapter 1: The Origins and Evolution of Utilization Review

Chapter 2: The Regulatory Environment

Chapter 3: The Business of Healthcare

Chapter 4: Utilization Review Services

Chapter 5: The Utilization Review Process: Pre-Admission and Admissions

Chapter 6: The Utilization Review Process: Continued Stay and Post-Acute Activities

Chapter 7: The Utilization Review Committee

Chapter 8: Leadership, Information, and Closing Comments

About the Authors:

Stefani Daniels, RN, MSNA, CMAC

Stefani Daniels, RN, MSNA, CMAC, is founder and senior advisor of Phoenix Medical Management, Inc., a boutique consulting company dedicated exclusively to hospital case management. She is a graduate of Villanova University and has held academic appointments at Columbia University, University of Pennsylvania, and Nova Southeastern School of Business and Entrepreneurship. She began her hospital experience as a critical care nurse back in the dark ages but spent most of her career in the executive suite of hospitals in New York, Pennsylvania, and Florida. She is a member of the editorial board of Lippincott’s Professional Case Management journal and the coauthor of the popular text The Leader’s Guide to Hospital Case Management and a contributing author to the 2nd and 3rd editions of CMSA’s Core Curriculum for Case Managers. In addition, while in slow retirement mode, Daniels remains a panel member of several webcast groups, including Appeal Academy’s Finally Friday and RAC Monitor’s Talk Ten Tuesday, when she isn’t skiing in Vermont or relaxing on a Fort Lauderdale beach.;

Ronald L. Hirsch, MD, FACP, CHCQM, CHRI

Ronald L. Hirsch, MD, FACP, CHCQM, CHRI, is vice president of R1 RCM in Chicago. Hirsch was the medical director of case management at Sherman Hospital in Elgin, Illinois. He is a member of the American Case Management Association, a member of the American College of Physician Advisors, and a fellow of the American College of Physicians. Hirsch serves as an advisory board member for NAHRI.