The Hospital Guide to Contemporary Utilization Review

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The Hospital Guide to Contemporary Utilization Review

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The Hospital Guide to Contemporary Utilization Review

Stefani Daniels, RN, MSNA, ACM, CMAC

Ronald L. Hirsch, MD, FACP, CHCQM

The Hospital Guide to Contemporary Utilization Review 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.

The book covers a range of topics, including compliance with the UR Condition of Participation, 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 utilization review (UR) program
  • Describe the legal obligations of the hospital to comply with chapter 42 CFR 482.30 of the Conditions of Participation (CoP)
  • Use the publication as a tool to assess his or her own hospital’s UR processes
  • Summarize the benefits of a dedicated UR team to promote compliance with the CoP
  • Facilitate the development of a contemporary UR committee
  • Assess an organization’s opportunities to improve processes to benefit patient care and hospital success
  • Recommend compliant language for the organization’s UR plan
  • Construct commercial contract language, in collaboration with the organization’s contract manager, that promotes a partnership to ensure appropriate use of acute care resources
  • Seek out operational resources to perform high-quality reviews that fully comply with the CoP
  • Explain the connection between a good utilization review plan and the hospital revenue cycle initiatives


Table of Contents

Chapter 1: History of Utilization Review 

  • Learning Objectives
  • Introduction
  • Terminology: Is It Utilization Review or Utilization Management?
  • History of Utilization Review


Chapter 2: The Regulatory Environment

  • Learning Objectives
  • Healthcare Regulations
  • Conditions of Participation
  • Insurance Contracts
  • The Regulatory Alphabet


Chapter 3: The Utilization Review Committee

  • Learning Objectives
  • Background Information
  • Committee Membership
  • Reporting Structure
  • Utilization Review Plan Content
  • The Utilization Review Committee Agenda
  • Data Support


Chapter 4: The Utilization Review Team and Its Partners

  • Learning Objectives
  • The Utilization Review Team
  • The Utilization Review Specialist
  • First-Level Reviewers
  • Virtual Utilization Review
  • Second-Level Reviewers
  • The Physician Advisor
  • Outsourced Resources
  • Staffing
  • Case Managers
  • Residents, Hospitalists, and Private Attending Physicians
  • The Revenue Cycle Team

 
Chapter 5: The Utilization Review Process

  • Learning Objectives
  • Defining Medical Necessity
  • Prospective Reviews for Elective Admissions
  • Pre-Certification for Elective Services
  • Medicare Inpatient-Only List
  • Elective Medical Admissions
  • Concurrent Reviews for Emergent Conditions
  • The 2-Midnight Rule
  • Practical Application of the 2-Midnight Rule
  • Practical Application Using Screening Tools
  • Other Practical Applications of the 2-Midnight Rule
  • Exceptions to the 2-Midnight Rule
  • Applying the 2-Midnight Rule to Transfer Patients
  • Medical Documentation and the Utilization Review Process
  • About Observation Services
  • Continued-Stay Review
  • Continued-Stay Review for Treatment of Primary Disease
  • Continued-Stay Review for Additional Testing
  • Determination of Proper Status
  • Level of Care Within the Hospital
  • Secondary Review

 
Chapter 6: Tools, Training, and Resources for the Utilization Review Team

  • Learning Objectives
  • Resources for Utilization Review Specialists
  • Training and Education
  • Nationally Recognized Acute Care Criteria
  • Best Practice Protocols
  • Regulatory Updates
  • OIG Work Plan
  • Commercial Contract Information
  • National and Local Coverage Determinations
  • Surgical and Nonsurgical Invasive Criteria

 
Chapter 7: Progression of Care

  • Learning Objectives
  • Effective Progression of Care
  • Objective Outcomes
  • Supplier Information
  • Physician-Specific Practice Profiles
  • Physician-Specific Denial Information
  • Progression-of-Care Delays and Avoidable Days
  • Discharge Planning and the Utilization Review Function
  • Utilization Review Documentation

 
Chapter 8: Legal and Ethical Considerations

  • Learning Objectives
  • Ethical and Legal Obligations for Utilization Review
  • Principles of Medical Ethics
  • Legal Considerations
  • Regulatory Issues Relevant to the Utilization Review Specialist
  • Advance Beneficiary Notice
  • Hospital Issued Notices of Non-Coverage
  • Certification of Admissions
  • Condition Code 44
  • Self-Denial of Inpatient Admissions


Who should read this book?

  • Case managers
  • UR coordinators
  • UR committee members
  • UR physician advisors
  • Nurse managers
  • Revenue cycle managers
  • Compliance officers and auditors
  • Healthcare lawyers and consultants

 

Continuing Educatin

American Nurses Credentialing Center (ANCC)
HCPro is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

This educational activity for three nursing contact hours is provided by HCPro.

Nursing contact hours for this activity are valid from April 27, 2015, through April 27, 2017.

California Board of Registered
HCPro is approved by the California Board of Registered Nursing to provide 3.6 nursing contact hours. California BRN Provider #CEP 14494.

Commission for Case Manager Certification (CCMC)
This program has been pre-approved by the Commission for Case Manager Certification to provide continuing education credit to CCM board certified case managers. The program is approved for nine CE contact hours.


About the Authors

Stefani Daniels, RN, MSNA, ACM, CMAC, is founder and managing partner of Phoenix Medical Management in Pompano Beach, Florida. She is a member of the editorial boards of HCPro’s Case Management Monthly, Lippincott’s Professional Case Management journal, and the Case Management Society of America’s (CMSA) Today. She is the coauthor of the popular text The Leader’s Guide to Hospital Case Management and a contributing author to CMSA’s Core Curriculum for Case Managers, Second Edition. Daniels’ articles appear in many healthcare journals and magazines, and she is a popular speaker on contemporary care management at regional and national venues. 

Ronald L. Hirsch, MD, FACP, CHCQM, is vice president at AccretivePAS® Clinical Solutions in Chicago. He is a general internist and HIV specialist. Dr. Hirsch was the medical director of case management at Sherman Hospital in Elgin, Illinois. He is certified in healthcare quality and management by the American Board of Quality Assurance and Utilization Review Physicians. In addition, 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.

Disclosure statement
The planners, presenters/authors, and contributors of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.


Published: April 2015

Page count: 158
Dimensions: 8.5x11
ISBN: 978-1-55645-214-7